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Which out of the three is accomplished through precertification?

A.

Concurrent review

B.

Retrospective review

C.

Prospective review

Which of the following is WRONG?

A.

Computer Based Patient Records Institute (CPRI) developed the standards for digital imaging of xrays.

B.

HL7 developers focuses on interchange of Clinical Health Data

C.

ANSI, a voluntary national standards organization, creates a consensus based process by which fair and equitable standards can be developed and serves as a legitmizer of standards.

D.

American Health Information Management Association focuses on EDI standards for exchange of clinical data

The following statements are about preferred provider organizations (PPOs). Select the answer choice that contains the correct statement.

A.

PPOs generally assume full financial risk for arranging medical services for their members.

B.

PPOs generally pay a larger portion of a member's medical expenses when that member uses in-network providers than when the member uses out-of-network providers.

C.

PPO networks may include primary care physicians and hospitals, but generally do not include specialists.

D.

In a PPO, the most common method used to reimburse physicians is capitation.

The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored

A.

anti selection

B.

cost shifting

C.

receivership

D.

underwriting

Keith Murray is a 45 year old chartered accountant & is employed in Livingstone consultancy firm. He has been paying payroll taxes for the past 15 years. Which of the following statements is true regarding Medicare Part A entitlement?

A.

Keith shall be entitled to Part A benefits when he attains 65 years of age

B.

Keith’s wife shall be entitled to Part A benefits when she attains 65 years of age

C.

Keith’s wife shall be required to pay a monthly premium in order to receive Medicare Part A benefits

D.

Both a & b

The Madison Health Plan, a national MCO, and a local hospital system that operates its own managed healthcare network recently created a new and separate managed healthcare organization, the Pineapple Health Plan. Madison and the hospital system share own

A.

a consolidation

B.

a joint venture

C.

a merger

D.

an acquisition

Which of the following statements is true?

A.

A declining economy can lead to lower healthcare costs as a result of an older population with greater healthcare needs.

B.

A larger patient population increases pressure on the health plan to offer larger panels.

C.

Provider networks are not affected by the federal and state laws that apply to health plans

D.

Network management standards established by independent accrediting organizations have no influence on health plan network design.

The act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage is:

A.

ERISA

B.

COBRA

The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's

A.

Hold all funds it receives on behalf of Titanium in trust.

B.

Assume full responsibility for ensuring that the health plan is administered properly

C.

Obtain from the federal government a certificate of authority designating the organization as a TPA.

D.

Assume full responsibility for determining the claim payment procedures for the plan

The process of identifying and classifying the risk represented by an individual or group is called

A.

Rating

B.

Anti selection

C.

Underwriting

D.

None of the above