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

Claims adjudication is the process by which an insurance company reviews a submitted claim, verifies coverage, and determines the appropriate payment amount.

Question 2

What does COBRA allow employees to do?

Accepted Answer

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

Answer

COBRA (Consolidated Omnibus Budget Reconciliation Act) allows employees and their families to continue group health insurance coverage for a limited time after losing eligibility due to qualifying events such as job loss.

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

Value-based contracts link provider reimbursement to the quality, efficiency, and outcomes of care rather than the volume of services provided.

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

The ACA requires non-grandfathered individual and small group plans to cover 10 categories of essential health benefits, including emergency services, hospitalization, and preventive care.

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

Adverse selection occurs when higher-risk individuals are more likely to seek and purchase insurance, potentially leading to an insured pool with higher-than-average healthcare costs.

CMSM - Certified Medical Services Manager Practice Test

CMSM - Certified Medical Services Manager Practice Test

CMSM Managed Care and Insurance Operations 3