Chapter 5 CPMA Exam Contract-based Commercial Insurance Plans Questions and Answers

Chapter 5 CPMA Exam Contract-based Commercial Insurance Plans Questions and Answers Most common commercial insurance plans are - Answer ️️ contract based That is, benefits arise primarily under a contract between the insurance company and the subscriber/patient Where the healthcare provider is in network, - Answer ️️ the provider agrees to abide by certain rules in a separate contract.. The auditor must review the contract to determine the rules the provider is bound to follow For commercial insurance plans, determine if the providers is obligate to - Answer ️️ conform to the insurance company's published medical policies Cigna requires par and nonpars to conform if want reimbursment If a commercial insurance plan requires the provider to conform to insurance company's published medical policies, determinis non-conformance - Answer ️️ entitles the payer to recoup the money, or is the only sanction potential termination of the provider network status? Is the provider offered a chance at implementing corrective action?