CCS Network Fundamentals 2

Question 1

A patient receives care from a provider who has not signed a participation agreement with the patient's insurer. How is this provider classified?

Accepted Answer

Out-of-network provider

Answer

A provider without a participation agreement with the insurer is classified as out-of-network, typically resulting in higher patient cost-sharing.

Question 2

Which term describes the process by which a health plan verifies that a provider meets its qualifications and standards before joining the network?

Accepted Answer

Provider credentialing

Answer

Provider credentialing is the process of verifying a provider's education, licensure, malpractice history, and other qualifications before network participation.

Question 3

In a PPO plan, a member who chooses an out-of-network provider will generally face:

Accepted Answer

Higher cost-sharing than in-network

Answer

PPO plans allow out-of-network use but impose higher cost-sharing (higher deductibles, coinsurance, or copays) compared to in-network care.

Question 4

What is a 'carve-out' in the context of managed care networks?

Accepted Answer

A separate benefit or service managed by a different entity

Answer

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.

Question 5

Network adequacy standards primarily ensure that:

Accepted Answer

Members have reasonable access to covered services

Answer

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.

(CCS) Certified Coding Specialist Practice Test

(CCS) Certified Coding Specialist Practice Test

CCS Network Fundamentals 2