HOM 5307 Exam 3 Questions and Correct Verified
Answers
which of the following is the leading reason for member complaints?
claims issues
applicants/groups with poor credit histories may be required to do which of the following?
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?
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
false
T/F member services and membership services are synonymous terms
false
T/F ERISA is the summary plan description is a booklet that describes the operative provisions
of a plan in lay terms
true
T/F durable medical equipment suppliers are not considered high risk operations for fraud
control
false
what are intermediaries in the employer sponsored business called?
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
false
what is the single most significant piece of social legislation since 1965?
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
true
T/F state mandated benefits laws apply to self funded employee benefits plans
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
medicare coverage
a managed care info system should be relied on for what core operational competencies?
-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
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
false
Answers
which of the following is the leading reason for member complaints?
claims issues
applicants/groups with poor credit histories may be required to do which of the following?
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?
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
false
T/F member services and membership services are synonymous terms
false
T/F ERISA is the summary plan description is a booklet that describes the operative provisions
of a plan in lay terms
true
T/F durable medical equipment suppliers are not considered high risk operations for fraud
control
false
what are intermediaries in the employer sponsored business called?
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
false
what is the single most significant piece of social legislation since 1965?
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
true
T/F state mandated benefits laws apply to self funded employee benefits plans
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
medicare coverage
a managed care info system should be relied on for what core operational competencies?
-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
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
false
