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HEALTH INSURANCE CHAPTER 13

CHAPTER 13 TEST
STUDY
PLAY
FALSE
BLUE CROSS AND BLUE SHIELD BEGAN AS TWO SEPARATE FEE-FOR-SERVICE HEALTH PLANS
TRUE
THE AMERICAN HOSPITAL ASSOCIATION (AHA) IS THE APPROVING AGENCY FOR ACCREDITATION OF NEW PREPAID HOSPITALIZATION PLANS
TRUE
FOR-PROFIT CORPORATIONS PAY TAXES ON PROFITS GENERATED BY THE CORPORATION'S FOR-PROFIT ENTERPRISES AND PAY DIVIDENDS TO SHAREHOLDERS ON AFTER-TAX PROFITS
FALSE
BCBS PLANS DO NOT NEED TO OBTAIN APPROVAL FROM THEIR RESPECTIVE STATE INSURANCE COMMISSIONERS FOR ANY RATE INCREASES AND/OR BENEFIT CHANGES
TRUE
FOR-PROFIT COMMERCIAL PLANS HAVE THE RIGHT TO CANCEL A POLICY AT RENEWAL TIME IF THE PATIENT IS A HIGH USER OF BENEFITS
FALSE
BCBS PLANS DO NOT HAVE TO GUARANTEE THE TRANSFER OF MEMBERSHIP FROM GROUP PLAN TO INDIVIDUAL WHEN THE POLICYHOLDER MOVES INTO AN AREA SERVED BY DIFFERENT BCBS CORPORATION
TRUE
A PARTICIPATING PROVIDER AGREES TO WRITE OFF THE DIFFERENCE OR BALANCE BETWEEN THE AMOUNT CHARGED BY THE PROVIDER AND THE APPROVED FEE ESTABLISHED BY THE INSURER
TRUE
BCBS CORPORATIONS CONDUCT REGULAR TRAINING SESSIONS FOR PAR BILLING STAFF
TRUE
THE PREFERRED PROVIDER NETWORK (PPN) IS A PROGRAM THAT REQUIRES PROVIDERS TO ADHERE TO MANAGED CARE PROVISIONS
FALSE
A PATIENT CANNOT BE ASKED TO PAY A NON-PAR IN FULL ON THE DAY OF SERVICE
TRUE
BCBS FEE-FOR-SERVICE IS ALSO KNOWN AS TRADITIONAL COVERAGE
TRUE
RIDERS ARE SPECIAL CLAUSES STIPULATING ADDITIONAL COVERAGE OVER AND ABOVE THE STANDARD CONTRACT
FALSE
CONDITIONS SUCH AS "ACUTE RESPIRATORY INFECTION' OR "BLADDER INFECTION" ARE CONSIDERED MEDICAL EMERGENCY DIAGNOSES
FALSE
THE OUTPATIENT PRETREATMENT AUTHORIZATION PLAN REQUIRES PREAUTHORIZATION OF OUTPATIENT AMBULATORY SURGICAL CARE
FALSE
THE MANDATORY SECOND SURGICAL OPINION REQUIREMENT IS NECESSARY WHEN A PATIENT IS ADMITTED FOR SURGERY THROUGH THE EMERGENCY DEPARTMENT
ALL OF THE ABOVE
BLUE CROSS BLUE SHIELD COVERAGE INCLUDES THE FOLLOWING PROGRAMS _________ A) FEE-FOR-SERVICE, B) MANAGED CARE PLANS, C) MEDICARE SUPPLEMENTAL PLANS, D) ALL OF THE ABOVE
AN HMO
AN EXCLUSIVE PROVIDER ORGANIZATION (EPO) IS SIMILAR TO_________
A) MEDICARE
B) AN HMO
C) A PAR
D) NONE OF THE ABOVE
NONE OF THE ABOVE
A PCP IS A_________
A) PRIMARY CARE PROVIDER
B) PERSONAL CARE PHYSICIAN
C) PERSONAL CARE PROVIDER
D) NONE OF THE ABOVE
100% OF NONSURGICAL CARE RENDERED WITH 24-72 HOURS
A SPECIAL ACCIDENTAL INJURY RIDER COVERS __________
A) 100% OF SURGICAL CARE RENDERED WITHIN 24-72 HOURS
B) 80% OF SURGICAL CARE RENDERED WITHIN 24-72 HOURS
C) 100% OF NONSURGICAL CARE RENDERED WITH 24-72 HOURS, D) 80% OF NONSURGICAL CARE RENDERED WITH 24-72 HOURS
D) 100% OF NONSURGICAL CARE RENDERED WITH 24-72 HOURS
ALLOWS SUBSCRIBERS TO CHOOSE BETWEEN A NETWORK PROVIDER OR OUT-OF-NETWORK PROVIDER
A POINT OF SERVICE PLAN (POS)_______ A) ALLOWS SUBSCRIBERS TO CHOOSE BETWEEN A NETWORK PROVIDER OR OUT-OF-NETWORK PROVIDER
B) REQUIRES SUBSCRIBERS TO CHOOSE A NETWORK PROVIDER
C) REQUIRES SUBSCRIBERS TO CHOOSE AN OUT-OF-OF NETWORK PROVIDER
D) NONE OF THE ABOVE
A SUBSCRIBER-DRIVEN PROGRAM
THE BCBS PPO PLAN IS_____
A) A CAPITATED PROGRAM
B) A FEE-FOR-SERVICE PROGRAM
C) A SUBSCRIBER-DRIVEN PROGRAM
D) A NONCAPITATED PROGRAM
R
THE FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM CARDS CONTAIN THE PHRASE GOVERNMENT WIDE SERVICE BENEFIT PLAN AND EMPLOYEES HAVE IDENTIFICATION NUMBERS THAT BEGIN WITH THE LETTER______
A) G
B) F
C) S
D) R
ALLOWS MEMBERS TO HAVE ACCESS TO BENEFITS THROUGHOUT THE UNITED STATES AND WORLD
HEALTHCARE ANYWHERE______
A) ALLOWS MEMBERS TO RECEIVE HEALTH CARE THROUGHOUT THE UNITED STATES
B) ALLOWS MEMBERS TO RECEIVE HEALTH CARE FROM ANY PARTICIPATING PROVIDER
C) ALLOWS MEMBERS TO HAVE ACCESS TO BENEFITS THROUGHOUT THE UNITED STATES AND WORLD
D) ALLOWS MEMBERS TO RECEIVE HEALTH CARE FROM ANY NONPARTICIPATING PROVIDER
EMPLOYEES AND DEPENDENTS WHO SPEND MORE THAN SIX MONTHS OUTSIDE THE U.S.
BLUEWORLDWIDE EXPAT PROVIDES MEDICAL COVERAGE FOR______
A) EMPLOYEES AND DEPENDENTS WHO SPEND MORE THAN SIX MONTHS OUTSIDE THE U.S.
B) EMPLOYEES WHO ARE NOT U.S. CITIZENS
C) EMPLOYEES WITH DISABILITIES
D) SINGLE EMPLOYEES WITH NO DEPENDENTS
20% - 25%
THE MOST COMMON COINSURANCE AMOUNTS RANGE FROM ________
A) 10% - 20%
B) 20% - 35%
C) 20% - 25%
D) 20% - 50%
BOTH B AND C
WHEN A PATIENT IS COVERED BY PRIMARY AND SECONDARY OR SUPPLEMENTAL BLUE CROSS BLUE SHIELD HEALTH INSURANCE PLANS ________
A) THE PROVIDER MUST SEND A SEPARATE CLAIM TO EACH ONE
B) NO CLAIM IS NEEDED FOR THE SECONDARY OR SUPPLEMENTAL CLAIM
C) MODIFICATIONS AE MADE TO THE CMS-1500 CLAIM
D) BOTH B AND C
HOSPITAL BILLS
BLUE CROSS PLAN WERE INITIATED IN 1929 AND ORIGINALLY PROVIDED COVERAGE FOR _______
A) OUTPATIENT BILLS
B) PHYSICIAN BILLS
C) HOSPITAL BILLS
D) AMBULATORY SURGICAL CENTER BILLS
PHYSICIAN SERVICES
BLUE SHIELD WAS CREATED IN 1938 AND ORIGINALLY COVERED ________
A) PHYSICIAN SERVICES
B) HOSPITAL SERVICES
C) AMBULATORY SURGICAL CENTER SERVICES
D) PHARMACY SERVICES
A REMITTANCE ADVICE
WHICH OF THE FOLLOWING IS ATTACHED WHEN COMPLETING SECONDARY CLAIMS ________?
A) AN EXPLANATION OF BENEFITS
B) A PAST DUE INVOICE
C) A REMITTANCE ADVICE
D) NONE OF THE ADVICE
ONE YEAR FROM DATE OF SERVICE
THE DEADLINE FOR FILING BLUE CROSS BLUE SHIELD CLAIMS IS _______ A) 30 DAYS FROM DATE OF SERVICE
B) ONE YEAR FROM DATE OF SERVICE
C) 60 DAYS FROM DATE OF SERVICE
D) 6 MONTHS FROM DATE OF SERVICE
INDEMNITY COVERAGE
FREEDOM TO USE ANY LICENSED HEALTH CARE PROVIDER
PAR
PROVIDER WITH CONTRACT WITH BCBS
SPECIAL ACCIDENTAL INJURY RIDER
100% ON NONSURGICAL CARE RENDERED WITHIN 72 HOURS OF ACCIDENTAL INJURY
BLUEWOLRDWIDE EXPAT
GLOBAL MEDICAL COVERAGE FOR EMPLOYEES WHO WORK OUTSIDE THE UNITED STATES
COORDINATED HOME HEALTH AND HOSPICE CARE
ALTERNATIVE TO ACUTE CARE SETTING
BCBS BASIC COVERAGE BENEFIT
DIAGNOSTIC LABORATORY SERVICES
MEDICARE SUPPLEMENTAL PLANS
PLANS AUGMENT MEDICARE PROGRAM
NONPROFIT CORPORATION
CHARITABLE, EDUCATIONAL, CIVIC, OR HUMANITARIAN ORGANIZATION
OPAP
PROSPECTIVE AUTHORIZATION
MEDICAL EMERGENCY CARE RIDER
IMMEDIATE TREATMENT SOUGHT AND RECEIVED FOR SUDDEN, SEVERE CONDITION
HEALTHCARE ANYWHERE
ACCESS TO HEALTH BENEFITS AROUND THE WORLD
FEHBP
FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM
PPN
MUST ADHERE TO MANAGED CARE PROVISIONS
EXCLUSIVE PROVIDER ORGANIZATION (EPO)
NO COVERAGE PROVIDED FOR SERVICES OUTSIDE THE NETWORK
BCBS MAJOR MEDICAL BENEFIT
MENTAL HEALTH BENEFITS