CMSM Managed Care and Insurance Operations 3

Question 1

What is 'claims adjudication' in health insurance?

Accepted Answer

The process by which an insurer reviews and processes a claim to determine payment

Answer

The process of filing an appeal for a denied claim

Answer

A legal dispute resolution process between providers and insurers

Answer

The audit of a provider's billing practices

Question 2

What does COBRA allow employees to do?

Accepted Answer

Continue group health insurance coverage after losing eligibility due to qualifying events

Answer

File a complaint against their employer for benefits violations

Answer

Opt out of employer-sponsored insurance without penalty

Answer

Convert group insurance to an individual policy at no additional cost

Question 3

What is a 'value-based contract' in managed care?

Accepted Answer

A payment arrangement that ties reimbursement to the quality and outcomes of care delivered

Answer

A contract that fixes prices based on the lowest market rate

Answer

A contract that limits the total value of services a provider can bill

Answer

An agreement that sets the monetary value of each medical procedure

Question 4

Under the Affordable Care Act (ACA), what does 'essential health benefits' refer to?

Accepted Answer

Ten categories of services that non-grandfathered individual and small group plans must cover

Answer

Benefits that are considered optional but recommended for good health

Answer

The minimum benefits required for Medicare and Medicaid plans

Answer

Benefits provided at no cost to all insured individuals

Question 5

What is 'adverse selection' in health insurance?

Accepted Answer

The tendency for higher-risk individuals to be more likely to purchase insurance

Answer

The practice of insurers selecting only healthy patients for coverage

Answer

The negative impact of poor coverage choices on patient outcomes

Answer

The process of selecting providers with poor performance records for exclusion

Question 6

What is a 'medical loss ratio' (MLR)?

Accepted Answer

The percentage of premium revenue that an insurer spends on medical care and quality improvement

Answer

The ratio of administrative expenses to total premiums collected

Answer

The ratio of denied claims to total claims submitted

Answer

The proportion of patients who experience adverse outcomes

Question 7

What is a 'point-of-service' (POS) plan?

Accepted Answer

A hybrid plan combining HMO and PPO features, allowing out-of-network care at higher cost

Answer

A plan that only provides coverage at the point of care, not for follow-up services

Answer

A plan that requires payment at the time of service with full reimbursement later

Answer

A plan that provides coverage only at specific contracted service locations