CMSM Managed Care and Insurance Operations 2

Question 1

What is an Explanation of Benefits (EOB)?

Accepted Answer

A statement sent to patients explaining how a claim was processed and what was paid

Answer

A document explaining the patient's rights under their insurance plan

Answer

A summary of the benefits included in an insurance policy

Answer

A form used to appeal denied insurance claims

Question 2

What distinguishes 'in-network' providers from 'out-of-network' providers?

Accepted Answer

In-network providers have contracted with the insurance plan at negotiated rates; out-of-network providers have not

Answer

In-network care is only available for emergency services

Answer

Out-of-network providers have agreed to accept the insurance plan's negotiated rates; in-network have not

Answer

There is no difference in cost between in-network and out-of-network care

Question 3

What is a 'formulary' in the context of prescription drug coverage?

Accepted Answer

A list of prescription drugs covered by an insurance plan

Answer

A list of approved diagnostic procedures covered by insurance

Answer

A standard form used to submit prescription claims

Answer

The maximum number of prescription refills allowed per year

Question 4

What does 'subrogation' mean in health insurance?

Accepted Answer

The right of an insurer to recover costs from a third party responsible for a patient's injury

Answer

The substitution of a less expensive drug for a brand-name drug

Answer

The transfer of insurance coverage from one plan to another

Answer

The process of substituting one provider for another in a patient's care team

Question 5

What is an 'out-of-pocket maximum' (stop-loss) provision in health insurance?

Accepted Answer

A cap on the total amount a member must pay for covered services in a plan year

Answer

A clause that stops coverage once a maximum benefit is reached

Answer

A provision that stops premium increases after a certain age

Answer

A rule that prevents insurers from canceling coverage mid-year

Question 6

In managed care, what role does a 'gatekeeper' serve?

Accepted Answer

A primary care physician who coordinates care and authorizes specialist referrals

Answer

A hospital administrator who controls access to specialty departments

Answer

An insurance company representative who approves or denies claims

Answer

A utilization review nurse who manages inpatient stays

Question 7

What is the purpose of a 'network adequacy' standard?

Accepted Answer

To ensure that insurance plan networks have sufficient providers for members to access timely care

Answer

To ensure that network providers have adequate malpractice insurance

Answer

To set minimum quality standards for providers joining a network

Answer

To determine the maximum number of patients each provider can accept