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
Which network model employs salaried physicians who work exclusively at the plan's own facilities?
Answer: Staff Model HMO
A staff model HMO directly employs physicians as salaried staff who practice exclusively within the HMO's own clinics or medical centers.
What is the primary purpose of a network's 'most favored nation' (MFN) clause in provider contracts?
Answer: Ensuring the payer receives rates at least as low as those offered to other payers
An MFN clause requires a provider to give the contracting payer rates no higher than those offered to any other payer, ensuring the plan receives competitive pricing.
A patient enrolled in a Point-of-Service (POS) plan visits a specialist without a referral from their primary care physician. This will likely result in:
Answer: Coverage as if out-of-network with higher cost-sharing
POS plans require a PCP referral for in-network specialist visits; bypassing this process typically results in the claim being processed at out-of-network benefit levels.
An Independent Practice Association (IPA) model HMO differs from a staff model primarily because:
Answer: IPA physicians maintain private practices and contract with the HMO
In an IPA model, the HMO contracts with an association of independent physicians who continue to see patients from other plans in their own private practices.
Which term describes a single entity that combines the functions of an insurer and a healthcare provider?
Answer: Integrated Delivery System (IDS)
An Integrated Delivery System (IDS) combines hospitals, physician groups, and insurance functions under one organizational structure to coordinate and finance care.
A payer identifies that a provider's network contract has expired but claims are still being processed. The provider should now be considered:
Answer: A non-participating (out-of-network) provider
Once a provider contract expires, the provider loses participating status and should be treated as non-participating/out-of-network until a new agreement is executed.
In the context of healthcare networks, what does 'geo-access' standard mean?
Answer: Distance and travel time requirements for member access to providers
Geo-access standards define maximum allowable distances or travel times between members and network providers to ensure geographic accessibility of care.