HOM 5307 Exam 3 Questions and Correct
Verified Answers
T/F the most common reason cited by physicians for limiting their practice to
medicaid consumers was low reimbursement rates
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
true
which are key supporting functions of the member services center?
-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
structure
T/F it is important for all CSRs to be able to address all aspects of plan operations
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
true
T/F all accredited health plans are required to report on their clinical performance
through HEDIS
, 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
utilization management
member services are responsible for
- providing info to members
-helping members with any problems
-handling member grievances and complaints
-tracking and reporting patterns of problems encountered
-enhancing the relationship between the members of the plan and the plan itself
T/F ERISA preempts all state laws
false
the best data source for any health plan is ___________ because it implicitly recognizes all
the plan specific characteristics
experience
T/F practice guidelines that can be repeated over and over again with the same result
are always considered to be valid
false
T/F while the federal gov requires medicare plans to submit performance data, most
participation in such programs is voluntary
false
T/F the most common form of claims submissions is electronic
true
Verified Answers
T/F the most common reason cited by physicians for limiting their practice to
medicaid consumers was low reimbursement rates
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
true
which are key supporting functions of the member services center?
-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
structure
T/F it is important for all CSRs to be able to address all aspects of plan operations
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
true
T/F all accredited health plans are required to report on their clinical performance
through HEDIS
, 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
utilization management
member services are responsible for
- providing info to members
-helping members with any problems
-handling member grievances and complaints
-tracking and reporting patterns of problems encountered
-enhancing the relationship between the members of the plan and the plan itself
T/F ERISA preempts all state laws
false
the best data source for any health plan is ___________ because it implicitly recognizes all
the plan specific characteristics
experience
T/F practice guidelines that can be repeated over and over again with the same result
are always considered to be valid
false
T/F while the federal gov requires medicare plans to submit performance data, most
participation in such programs is voluntary
false
T/F the most common form of claims submissions is electronic
true
