HOM 5307 EXAM 2 QUESTIONS AND
ANSWERS 100% CORRECT.
which of the following is the leading reason for member complaints? - ANSWER claims
issues
applicants/groups with poor credit histories may be required to do which of the
following? - ANSWER produce some form of collateral, produce a letter of credit & pay
premiums in advance of the coverage period
todays transactional processing systems auto adjudicate on average what percentage
of claims that are accepted into the processing system? - ANSWER 75%
T/F although important, the provision of general info to members should not be
considered to be one of the key aspects of member services - ANSWER false
T/F member services and membership services are synonymous terms - ANSWER
false
T/F ERISA is the summary plan description is a booklet that describes the operative
provisions of a plan in lay terms - ANSWER true
T/F durable medical equipment suppliers are not considered high risk operations for
fraud control - ANSWER false
what are intermediaries in the employer sponsored business called? - ANSWER
brokers and consultants
T/F consumers and small employers may shop for and purchase health insurance
through the exchange as a result of the children's health insurance reauthorization act
of 2009 - ANSWER false
what is the single most significant piece of social legislation since 1965? - ANSWER the
patient protection & affordable care act of 2010
T/F effective fraud control must include ongoing and agile enhancements to efforts of
fraud detection and prevention - ANSWER true
T/F state mandated benefits laws apply to self funded employee benefits plans -
ANSWER false
, which of the following is NOT a reason for the growing interest in medicaid programs
developing plans to serve dually eligible beneficiaries who also have - ANSWER
medicare coverage
a managed care info system should be relied on for what core operational
competencies? - ANSWER -benefit configuration & employer group and member
enrollment
-claims payment and premium management
-provider enrollment, contracting, and credentialing and customer services
T/F given the low payment rates in medicaid, there is no interest in developing
incentives or pay for performance programs - ANSWER false
T/F the institute of medicines committee on the quality of health care in america
proposed five aims for improvement in our health care system - ANSWER false
T/F the employee section between carrier options chosen by the employer is called the
second sale - ANSWER true
T/F the most common reason cited by physicians for limiting their practice to medicaid
consumers was low reimbursement rates - ANSWER true
"upstream" quality control refers to the processes and system files that govern and
enable automatic and manual claims adjudication. "downstream" quality control refers
primarily to the claims capability itself - ANSWER true
which are key supporting functions of the member services center? - ANSWER -
workforce management
-quality monitoring
a set of causes and conditions that come together in a series of steps to transfer inputs
into outcomes is called - ANSWER structure
T/F it is important for all CSRs to be able to address all aspects of plan operations -
ANSWER false
T/F providers, employers, agents and members expect many health plan services to be
available online. the preferred approach to allow access is through web portals and
interactive voice response systems - ANSWER true
T/F all accredited health plans are required to report on their clinical performance
through HEDIS - ANSWER false
to earn NCQA accreditation an organization must meet rigorous ________ standards
designed to ensure that this key health plan function promotes good medicine rather
than acting as an arbitrary barrier to care - ANSWER utilization management
ANSWERS 100% CORRECT.
which of the following is the leading reason for member complaints? - ANSWER claims
issues
applicants/groups with poor credit histories may be required to do which of the
following? - ANSWER produce some form of collateral, produce a letter of credit & pay
premiums in advance of the coverage period
todays transactional processing systems auto adjudicate on average what percentage
of claims that are accepted into the processing system? - ANSWER 75%
T/F although important, the provision of general info to members should not be
considered to be one of the key aspects of member services - ANSWER false
T/F member services and membership services are synonymous terms - ANSWER
false
T/F ERISA is the summary plan description is a booklet that describes the operative
provisions of a plan in lay terms - ANSWER true
T/F durable medical equipment suppliers are not considered high risk operations for
fraud control - ANSWER false
what are intermediaries in the employer sponsored business called? - ANSWER
brokers and consultants
T/F consumers and small employers may shop for and purchase health insurance
through the exchange as a result of the children's health insurance reauthorization act
of 2009 - ANSWER false
what is the single most significant piece of social legislation since 1965? - ANSWER the
patient protection & affordable care act of 2010
T/F effective fraud control must include ongoing and agile enhancements to efforts of
fraud detection and prevention - ANSWER true
T/F state mandated benefits laws apply to self funded employee benefits plans -
ANSWER false
, which of the following is NOT a reason for the growing interest in medicaid programs
developing plans to serve dually eligible beneficiaries who also have - ANSWER
medicare coverage
a managed care info system should be relied on for what core operational
competencies? - ANSWER -benefit configuration & employer group and member
enrollment
-claims payment and premium management
-provider enrollment, contracting, and credentialing and customer services
T/F given the low payment rates in medicaid, there is no interest in developing
incentives or pay for performance programs - ANSWER false
T/F the institute of medicines committee on the quality of health care in america
proposed five aims for improvement in our health care system - ANSWER false
T/F the employee section between carrier options chosen by the employer is called the
second sale - ANSWER true
T/F the most common reason cited by physicians for limiting their practice to medicaid
consumers was low reimbursement rates - ANSWER true
"upstream" quality control refers to the processes and system files that govern and
enable automatic and manual claims adjudication. "downstream" quality control refers
primarily to the claims capability itself - ANSWER true
which are key supporting functions of the member services center? - ANSWER -
workforce management
-quality monitoring
a set of causes and conditions that come together in a series of steps to transfer inputs
into outcomes is called - ANSWER structure
T/F it is important for all CSRs to be able to address all aspects of plan operations -
ANSWER false
T/F providers, employers, agents and members expect many health plan services to be
available online. the preferred approach to allow access is through web portals and
interactive voice response systems - ANSWER true
T/F all accredited health plans are required to report on their clinical performance
through HEDIS - ANSWER false
to earn NCQA accreditation an organization must meet rigorous ________ standards
designed to ensure that this key health plan function promotes good medicine rather
than acting as an arbitrary barrier to care - ANSWER utilization management
