Deck 8: Private Payersblue Cross and Blue Shield

Question 1

A ______ is a health plan that is sponsored by employer or employee organization to provide health care to the employees, former employees and their families.

A) group health plan
B) government health plan
C) collection group plan
D) congregation group plan

Answer 1

group health plan

Question 2

Who manages the group health care plan benefits, negotiating with payers and selecting a number of plans for the employer and employees?

A) the government
B) human resources
C) the insurance company
D) the medical assistant

Answer 2

human resources

Question 3

What is a document modifying an insurance contract called?

A) prerequisite
B) criterion
C) stipulation
D) rider

Answer 3

rider

Question 4

When an employer wishes to reduce the price of the standard employer-sponsored plan, he/she would negotiate with the health plan to change the options offered to the employees using what process?

A) rider
B) options
C) carve out
D) preferences

Question 5

During specified periods, employees choose the plan they prefer for the coming benefit period; this is called _______.

A) open enrollment
B) selection period
C) constraint period
D) selection period.

Question 6

The largest employer-sponsored health program in the United States, which covers more than 8 million federal employees, retirees, and their families through over 250 health plans from number of carriers, is called _______.

A) Personal Health Care Benefits program
B) Federal Employees Health Benefits program
C) Workforce Health Benefit program
D) Organizational Workforce Benefits program

Question 7

FEHB is the abbreviation for _____.

A) Federal Equality Health Benefits program
B) Federal Equivalence Health Benefits program
C) Federal Employees Health Benefits program
D) Federal Equal Opportunity Health Benefits program

Question 8

When an organization sets up a fund and pays for health insurance directly this is called ______.

A) collective health plan
B) self-insured health plan
C) non-deductible health plan
D) cooperative health plan

Question 9

Self-insured health plans are regulated by _______.

A) State Laws
B) Social Security Benefit Act
C) Federal Employees Health Benefits
D) Employee Retirement Income Security Act of 1974

Question 10

ERISA is the abbreviation for _____.

A) Employee Retirement Income Security Act of 1974
B) Employment Refuge Income Security Act of 1974
C) Engagement Retirement Income Security Act of 1974
D) Encounter Refuge Income Security Act of 1974

Question 11

Employee Retirement Income Security Act of 1974 (ERISA) are _____.

A) laws providing incentives for the insurance company
B) laws providing protection for the insurance company
C) laws providing incentives and protection for companies with employee health and pension plans
D) laws providing incentives and protection for federal employees only

Question 12

ERISA is operated by the ______.

A) Federal Department of Labor's Pension and Welfare Benefits Administration
B) Federal Department of Insurance Fraud
C) Federal Department of Covered Insurance for Retired Individuals
D) Federal Department of Retired Pension and Welfare Recipients Administration

Question 13

EBSA is the abbreviation for _______.

A) Federal Department of Insurance Benefits and Pension Administration
B) Federal Department of Retired Benefits and Pension Administration
C) Federal Department of Covered Insurance Benefits Administration
D) Federal Department of Labor's Pension and Welfare Benefits Administration

Question 14

The time between the date of hire and the date the insurance becomes effective is called _____.

A) postponing period
B) waiting period
C) suspending period
D) delaying period

Question 15

A (n) _____ is an individual who enrolls in a plan at a time other than the earliest possible enrollment date or a special enrollment date.

A) late enrollee
B) uninsured enrollee
C) overdue enrollee
D) belated enrollee

Question 16

A (n) ____ is a fixed amount that must be met periodically by each individual of an insured/dependent group.

A) individual deductible
B) group deductible
C) separate deductible
D) family deductible

Question 17

Under a managed health care plan, do the noncovered services that the patient must pay out-of-pocket, count toward satisfying a deductible?

A) only during the first six months of the coverage period
B) only during the last six months of the coverage period
C) no
D) yes

Question 18

A (n) ____ is the fixed, periodic amount that must be met by the combined payments of an insured/dependent group before benefits begin.

A) individual deductible
B) family deductible
C) collective deductible
D) household deductible

Question 19

The _____ is the monetary amount that plans often have after which benefits end, and where they may also impose a condition-specific lifetime limit.

A) capstone benefit limit
B) maximum benefit limit
C) highest benefit limit
D) superlative benefit limit

Question 20

The maximum benefit limit is also called _______.

A) capstone limit
B) lifetime limit
C) highest limit
D) superlative limit

Question 21

The law requiring employers with over twenty employees to allow terminated employees to pay for health coverage for eighteen months after termination is called _____.

A) Combined Insurance Reconciliation Act
B) Established Insurance Benefits for terminated employees
C) Consolidated Omnibus Budget Reconciliation Act
D) Mutual Omnibus Budget Act

Question 22

_______ gives an employee who is leaving a job the right to continue health coverage under the employers' plan for a limited time at his or her own expense.

A) COBRA
B) Terminated Employee Insurance
C) BRACO
D) AARP

Question 23

A (n) _____ is a medical insurance plan purchased by an individual.

A) individual health plan
B) unemployed family health plan
C) unwaged health plan
D) separate health plan

Question 24

A (n) ________ is a health plan , often without riders or additional features associated with the group health plan, that people elect to enroll in to continue their health insurance between jobs.

A) unemployed family health plan
B) individual health plan
C) separate health plan
D) unwaged health plan

Question 25

The ____ is a national organization of independent companies and a Federal Employee Program that insures nearly 100 million people.

A) HealthProviders
B) BlueCross BlueShield Association
C) Travelers
D) HealthState

Question 26

BCBS is the abbreviation for the _____.

A) BlueCross BlueShield Association
B) BlueKeepers BlueShield Association
C) BlueKeepers BlackShield Association
D) BlackCross BlackShield Association

Question 27

____ was founded in the 1930s to provide low-cost medical insurance.

A) the HealthProviders Association
B) the Travelers HealthProviders Association
C) the BlueCross BlueShield Association
D) the Health Contributors Association

Question 28

The _____ is an independent nonprofit organization and is the leader in accrediting HMOs and PPOs.

A) National Committee for Quality Assurance
B) National Organization for Quality Assurance
C) National Association for Quality Assurance
D) National Correlation for Quality Assurance

Question 29

________ sets and monitors standards for many types of patient care.

A) The Health Care Organization
B) The Government Commission on Health Standards
C) The Joint Commission
D) The BlueCross Commission on Health Standards

Question 30

The ______ helps alleviate the pressures facing physicians, health plans, and hospitals by reducing costs and administrative effort while simultaneously documenting quality.

A) American Medical Accreditation Program
B) Insurance Regulator Accreditation Program
C) National Medical Accreditation Program
D) American Technology Accreditation Program

Question 31

The _______ is another leading accrediting group addressing both the security and privacy of health information as required by HIPAA that is a nonprofit organization and establishes standards for managed health care plans.

A) Exploitation Review Accreditation Commission
B) Utilization Review Accreditation Commission
C) Development Review Accreditation Commission
D) Operation Review Accreditation Commission

Question 32

What program emphasizes an assessment of clinical records, enrollee and provider satisfaction, provider qualifications, utilization of resources, and quality of care?

A) Application Association for Ambulatory Health Care, Inc.
B) BlueShield Association for Ambulatory Health Care Providers, Inc.
C) BlueCross Association for Ambulatory Health Care, Inc.
D) Accreditation Association for Ambulatory Health Care, Inc.

Question 33

Which of the following is a nationwide program that makes it easy for patients to receive treatment when outside their local service area?

A) Outsource Program
B) BlueCross Program
C) BlueCard Program
D) Subcontract Program

Question 34

______ links participating providers and independent BCBS plans throughout the nation with a single electronic claim processing and reimbursement system.

A) BlueCard Program
B) Subcontract Program
C) Outsource Program
D) BlueCross Program

Question 35

Participating provider's local BCBS plan is called ____.

A) local plan
B) resident
C) host plan
D) denizen plan

Question 36

_____ is BCBS plan in the subscriber's community.

A) home plan
B) domestic plan
C) household plan
D) internal plan

Question 37

______ is BCBS consumer-driven health plan that combines a comprehensive PPO plan with an HSA, an HRA, or an FSA.

A) Bendable Blue
B) Flexible Blue
C) Plaint Blue
D) Compliant

Question 38

The types of services that the provider must offer to plan members are called ___.

A) covered services
B) enclosed services
C) enfolded services
D) encompassed services

Question 39

The payer's process for determining medical necessity is called _____.

A) exploitation review
B) relevance review
C) applicability review
D) utilization review

Question 40

When the practice decides to participate in a health care plan, it must follow the rules of the contract. Which is not one of the points to consider?

A) quality assurance/utilization review
B) acceptance of plan members
C) covered services
D) how many employees the facility must have

Question 41

What is protection against large losses or severely adverse claims experience called?

A) theft protection provision
B) embezzlement provision
C) stop-loss provision
D) pilfering provision

Question 42

Nonemergency surgical procedure is called ____.

A) discretionary surgery
B) elective surgery
C) selective surgery
D) discriminatory surgery

Question 43

What determines whether a participating provider can charge a patient for a product used to set up a procedure when the patient cancels?

A) the contract
B) the office manager
C) the physician
D) the convention

Question 44

What is an organization hired by a payer to evaluate medical necessity called?

A) exploitation review organization
B) utilization review organization
C) application review organization
D) operation review organization

Question 45

____ is preauthorization for hospital admission or outpatient procedures.

A) pre-certification
B) pre-documentation
C) pre-accreditation
D) pre-endorsement

Question 46

Another term for precertification is ______.

A) pre-documentation
B) pre-accreditation
C) pre-endorsement
D) pre-authorization

Question 47

A document of eligible members of a capitated plan for a monthly period is called ____.

A) monthly matriculation list
B) monthly membership list
C) monthly enrollment list
D) monthly registration list

Question 48

Who sends the claim to the BlueCross and BlueShield when the provider does not participate?

A) the PPN
B) the provider
C) the patient
D) the employer

Question 49

Who sends the claim to BlueCross and BlueShield when the provider participates?

A) the POS
B) the provider
C) the patient
D) the employer

Question 50

The BCBS Blue Card program provides benefits for subscribers who are away from their _____.

A) local areas
B) primary care providers
C) families
D) region

Question 51

A participating provider's local BlueCross and BlueShield plan is the _____.

A) foreign plan
B) nationwide plan
C) host plan
D) countrywide plan

Question 52

The BlueCross and BlueShield Association (BCBS) is a group of ______.

A) physicians
B) independent companies and a federal employee program
C) patients
D) government officials

Question 53

What health insurance plan may employees of the federal government select?

A) Flexible Blue plan
B) Federal Employee Health Benefits (FEHB) plan
C) Blue Protection plan
D) None federal government employees are not eligible

Question 54

BCBS administers the BlueCard Program, which is a (n) ____.

A) out-of-area program
B) local area program
C) home plan
D) coast to coast plan

Question 55

Why is insurance always verified?

A) to ensure the insurance company gets a discount
B) to ensure the physician gets a discount
C) to ensure the patient gets a discount
D) to be sure that the patient is eligible for services

Question 56

________ is the nation's largest health insurer in terms of enrollment and the largest owner of BlueCross and BlueShield plans.

A) WellPoint
B) HealthKeepers
C) Traveler
D) Allstate

Question 57

____ has a full range of products, including health care, dental, pharmacy, group life, behavioral health, disability and long-term care benefits and has more than 44 million members.

A) HealthKeepers
B) State Farm
C) Aetna
D) Allstate

Question 58

______ is a large health insurer with strong enrollment in the Northeast and the West.

A) CIGNA
B) Allstate
C) Northeast Insurance Group
D) West Insurance Group

Question 59

______ is a prepaid group practice that offers both health care services and insurance in one package and is the largest nonprofit HMO.

A) Aetna
B) HealthKeepers
C) Kaiser Permanente
D) CIGNA

Question 60

_______ operates health plans in the West and has group, individual, Medicare, Medicaid, and TRICARE programs.

A) Health Net
B) Aetna
C) Allstate
D) State Farm

Question 61

______ is particularly strong in the South and Southeast that offers both traditional and consumer-driven products.

A) Medicaid
B) Medicare
C) Humana
D) AARP

Question 62

______ handles TRICARE operations in the Southeast.

A) Humana
B) AARP
C) Medicare
D) Medicaid

Question 63

_______ is a national managed health care company based in Bethesda, Maryland that provides a full range of risk and fee-based managed care products and services.

A) Travelers Health Care
B) HealthKeepers Health Care
C) Coventry Health Care
D) AARP Health Care

Question 64

_____ is a type of managed care program where patient must choose a primary care physician who is in the network.

A) HMO
B) PPO
C) Medicaid
D) Medicare

Question 65

______ is an HMO program that provides emergency room coverage if the subscriber needs care when traveling.

A) Visa Care Program
B) Permit Care Program
C) Endorsement Care Program
D) Away From Home Care Program

Question 66

A _______ is a courtesy enrollment for members who are temporarily residing outside of their home HMO service area for at least ninety days.

A) Permit Membership
B) Guest Membership
C) Visitant Membership
D) Tourist Membership

Question 67

______ is a managed care program where members may receive treatment from a provider in the network, or they may choose to see a provider outside the network and pay a higher fee.

A) POS
B) PSO
C) POP
D) MHO

Question 68

_____ is a managed care program where physicians and other health care providers sign participation contracts agreeing to accept reduced fees in exchange for membership in the network.

A) HMO
B) AARP
C) PPO
D) POS

Question 69

Which of the following is not a main part of participation contract?

A) introductory section
B) physician's responsibilities
C) compensation and billing guidelines
D) procedural and diagnostic codes

Question 70

The participation contract stipulates some responsibilities of the plan toward the provider. Which of the following is not one of the responsibilities?

A) protection against loss
B) payments
C) contacting AARP
D) identification of enrolled patients

Question 71

Managed care contracts outline compensation and billing guidelines that include the fees that can be charged by the provider, billing rules, and _______.

A) the patient's financial responsibilities
B) the discount rates
C) the different services provided outside of the facility
D) the physician's license number

Question 72

Before services in capitated plans can begin, insurance coverage must be ____.

A) documented
B) verified
C) reported
D) conveyed