Network Fundamentals Flashcards
7 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Network Fundamentals flashcards as text
A patient receives care from a provider who has not signed a participation agreement with the patient's insurer. How is this provider classified?
Answer: Out-of-network provider
A provider without a participation agreement with the insurer is classified as out-of-network, typically resulting in higher patient cost-sharing.
Which term describes the process by which a health plan verifies that a provider meets its qualifications and standards before joining the network?
Answer: Provider credentialing
Provider credentialing is the process of verifying a provider's education, licensure, malpractice history, and other qualifications before network participation.
In a PPO plan, a member who chooses an out-of-network provider will generally face:
Answer: Higher cost-sharing than in-network
PPO plans allow out-of-network use but impose higher cost-sharing (higher deductibles, coinsurance, or copays) compared to in-network care.
What is a 'carve-out' in the context of managed care networks?
Answer: A separate benefit or service managed by a different entity
A carve-out separates a specific benefit (e.g., behavioral health or pharmacy) from the main health plan and manages it through a specialized entity.
Network adequacy standards primarily ensure that:
Answer: Members have reasonable access to covered services
Network adequacy standards require health plans to maintain a sufficient number and type of providers so members can access covered services in a timely manner.
A 'closed panel' HMO requires members to:
Answer: Use only providers employed by or exclusively contracted with the HMO
A closed-panel HMO restricts members to providers who are exclusively employed by or contracted with the HMO, offering no out-of-network coverage.
Which document formally establishes the contractual relationship between a provider and a health plan network?
Answer: Provider Participation Agreement
A Provider Participation Agreement outlines the terms, reimbursement rates, and obligations for both the provider and the health plan within the network.