HOM 5307 Lowell Lay 2025 Questions Answered 100%
The first and most rigorous area of NCQA review is:
a health plan's own internal quality control system
What two significant developments that have direct impact on the claims capability?
The transition form ICDD-9 to ICD-10 diagnosis and procedure codes and the patient protection
and Affordable Care Act of 2010.
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.
TRUE
Benefit determination is the process of automatically determining eligibility and correctly
applying benefits and payment terms for each claim using pre-determined rules without any
human intervention.
FALSE
Staffing ratios for the claims capability depend on the number needed to meet
volume demands while maintaining quality standards and not relying on overtime
hours as a permanent solution.
TRUE
Subrogation is defined as:
the right to recover any damages that member may receive from a third party who
assumes responsibility for an accidental injury.
A participating provider is permitted to balance bill a member for any amount not paid dur to
the application of a fee schedule or other provider payment mechanism.
FALSE
, Today's transactional processing systems auto adjudicate on average what percentage
of claims that are accepted into the processing system?
75%
What is a method for providing a complete picture of care delivered in all health
care settings?
Episodes of care
What specific factors other than diseases commonly affect severity of illness?
Culture, geographic location, sex, age
Health care claims costs are typically distributed evenly across all members.
FALSE
Why is data analysis an increasingly important health plan function?
Cost increases 2-3 times the consumer price index. Potential for improvements in medical
management. Third party consultants that specialize in data analysis and aggregate data
across health plans. (All of the above)
The first and most rigorous area of NCQA review is:
a health plan's own internal quality control system
What two significant developments that have direct impact on the claims capability?
The transition form ICDD-9 to ICD-10 diagnosis and procedure codes and the patient protection
and Affordable Care Act of 2010.
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.
TRUE
Benefit determination is the process of automatically determining eligibility and correctly
applying benefits and payment terms for each claim using pre-determined rules without any
human intervention.
FALSE
Staffing ratios for the claims capability depend on the number needed to meet
volume demands while maintaining quality standards and not relying on overtime
hours as a permanent solution.
TRUE
Subrogation is defined as:
the right to recover any damages that member may receive from a third party who
assumes responsibility for an accidental injury.
A participating provider is permitted to balance bill a member for any amount not paid dur to
the application of a fee schedule or other provider payment mechanism.
FALSE
, Today's transactional processing systems auto adjudicate on average what percentage
of claims that are accepted into the processing system?
75%
What is a method for providing a complete picture of care delivered in all health
care settings?
Episodes of care
What specific factors other than diseases commonly affect severity of illness?
Culture, geographic location, sex, age
Health care claims costs are typically distributed evenly across all members.
FALSE
Why is data analysis an increasingly important health plan function?
Cost increases 2-3 times the consumer price index. Potential for improvements in medical
management. Third party consultants that specialize in data analysis and aggregate data
across health plans. (All of the above)
