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

An EOB is a statement from the insurance company explaining how a claim was processed, including what was billed, what the insurer paid, and what the patient owes.

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 providers have contracted with the insurance plan and agreed to negotiated rates, resulting in lower out-of-pocket costs for members compared to out-of-network providers.

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 formulary is the list of prescription drugs covered by an insurance plan, typically organized into tiers that determine the patient's cost-sharing.

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

Subrogation gives an insurer the legal right to pursue a third party that caused an insurance loss to the insured, allowing the insurer to recover amounts it paid for the claim.

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

The out-of-pocket maximum caps the total amount a member must pay for covered services in a plan year; after reaching it, the insurer pays 100% of covered costs.

CMSM - Certified Medical Services Manager Practice Test

CMSM - Certified Medical Services Manager Practice Test

CMSM Managed Care and Insurance Operations 2