XCEL CHAPTER 5 EXAM 2025
QUESTIONS AND ANSWERS
What do Blue Cross and Blue Shield service providers offer in return for a premium? -
ANS Health care services from participating providers.
How do Blue Cross and Blue Shield plans operate in the U.S.? - ANS They are the dominant
health insurers, loosely affiliated through their national association.
What is the payment structure for Blue Cross and Blue Shield benefits? - ANS They pay the
provider directly for the subscriber's medical treatment.
What types of care does Blue Cross cover versus Blue Shield? - ANS Blue Cross pays for
hospital care, while Blue Shield covers physician fees.
1 @COPYRIGHT THEBRIGHT 2025/2026
,What is a characteristic of traditional service provider plans? - ANS They are considered
prepaid, with subscribers paying a fixed monthly fee for covered medical services.
What is the right of assignment in traditional medical insurance policies? - ANS It allows
insurers to pay providers directly.
What are traditional indemnity plans? - ANS Insurance plans that indemnify the insured and
are national in scope.
What is managed care? - ANS The process of controlling how policy owners utilize their
policies.
What is a mandatory second opinion in managed care? - ANS A requirement before elective
surgery to reduce unnecessary procedures for full coverage.
How do managed care programs encourage preventive care? - ANS By helping lower health
care costs through preventive measures.
2 @COPYRIGHT THEBRIGHT 2025/2026
, What are ambulatory surgical centers? - ANS Economical venues for outpatient procedures
with lower overhead expenses.
What is the purpose of case management in utilization review? - ANS To monitor potentially
large claims and discuss treatment alternatives.
What is precertification (prospective) review? - ANS Analyzing a case before admission to
determine necessary treatment and reduce hospitalizations.
What is concurrent review in managed care? - ANS Monitoring the appropriateness of care
as it is being provided.
What occurs during retrospective review? - ANS Reviewing medical records after treatment
to approve or deny coverage retroactively.
What are Health Maintenance Organizations (HMOs)? - ANS Organizations that offer
comprehensive prepaid health care services and deliver covered services.
3 @COPYRIGHT THEBRIGHT 2025/2026
QUESTIONS AND ANSWERS
What do Blue Cross and Blue Shield service providers offer in return for a premium? -
ANS Health care services from participating providers.
How do Blue Cross and Blue Shield plans operate in the U.S.? - ANS They are the dominant
health insurers, loosely affiliated through their national association.
What is the payment structure for Blue Cross and Blue Shield benefits? - ANS They pay the
provider directly for the subscriber's medical treatment.
What types of care does Blue Cross cover versus Blue Shield? - ANS Blue Cross pays for
hospital care, while Blue Shield covers physician fees.
1 @COPYRIGHT THEBRIGHT 2025/2026
,What is a characteristic of traditional service provider plans? - ANS They are considered
prepaid, with subscribers paying a fixed monthly fee for covered medical services.
What is the right of assignment in traditional medical insurance policies? - ANS It allows
insurers to pay providers directly.
What are traditional indemnity plans? - ANS Insurance plans that indemnify the insured and
are national in scope.
What is managed care? - ANS The process of controlling how policy owners utilize their
policies.
What is a mandatory second opinion in managed care? - ANS A requirement before elective
surgery to reduce unnecessary procedures for full coverage.
How do managed care programs encourage preventive care? - ANS By helping lower health
care costs through preventive measures.
2 @COPYRIGHT THEBRIGHT 2025/2026
, What are ambulatory surgical centers? - ANS Economical venues for outpatient procedures
with lower overhead expenses.
What is the purpose of case management in utilization review? - ANS To monitor potentially
large claims and discuss treatment alternatives.
What is precertification (prospective) review? - ANS Analyzing a case before admission to
determine necessary treatment and reduce hospitalizations.
What is concurrent review in managed care? - ANS Monitoring the appropriateness of care
as it is being provided.
What occurs during retrospective review? - ANS Reviewing medical records after treatment
to approve or deny coverage retroactively.
What are Health Maintenance Organizations (HMOs)? - ANS Organizations that offer
comprehensive prepaid health care services and deliver covered services.
3 @COPYRIGHT THEBRIGHT 2025/2026
