Sn

Front 1

A health care delivery system that controls utilization and cost of services while providing enrollees access to quality, cost-effective health care is called ___________ care.

Back 1

Managed

Front 2

Individuals who are members of a managed care plan are commonly referred to as

Back 2

Enrollees

Front 3

A group of health care providers working under one umbrella to provide medical services at a discount to the individuals who participate in the plan is called a

Back 3

PPO

Front 4

A specific provider who oversees the total health care treatment of an individual enrolled in certain managed care plans is a

Back 4

Primary care physician

Front 5

A relatively small out-of-pocket dollar amount that a member of a managed care plan typically pays up front is called

Back 5

A co-payment

Front 6

A health care provider trained in a specific medical specialty is a

Back 6

Specialist

Front 7

A multi-specialty practice in which health care services are provided within the building complex owned by the health maintenance organization (HMO) is a

Back 7

Staff model

Front 8

A type of HMO where services are provided by outpatient networks composed of individual health care providers who supply all necessary patient care is an

Back 8

IPA

Front 9

An advantage of managed care organizations (MCO) is at their aim is to keep their enrollees healthy, which is commonly referred to as

Back 9

Preventive care

Front 10

A private, non-profit organization that accredits health care plans based on evaluation of the quality of care given to plan members is the

Back 10

NCQA

Front 11

An independent, not-for-profit organization that sets standards for health care in the United States and accredits most major hospitals is the

Back 11

JCAHO

Front 12

The formal term for a written complaint submitted by an individual covered by a special plan or policy is

Back 12

Grievance

Front 13

A system designed to determine the medical necessity and appropriateness of a requested medical service or procedure is a

Back 13

Utilization review

Front 14

A procedure required by most health care plans before a provider carries out specific procedures or treatment is a

Back 14

Pre-authorization

Front 15

A request by a health care provider for his or her patient to be evaluated or treated by a specialist is known as a

Back 15

Referral

Front 16

A federal act, passed in 1996, which is intended to improve the efficiency of health care delivery, reduce administrative cost, and protect patient privacy is

Back 16

HIPAA

Front 17

A combination federal and state medical assistance program that provides comprehensive and quality medical care for certain categories of low-income and qualifying elderly people is

Back 17

Medicaid

Front 18

The acronym for the Medicaid program that was formerly referred to as AFDC is

Back 18

TANF

Front 19

To qualify for supplemental security income (SSI), individuals must meet certain guidelines set for by

Back 19

The federal poverty level (FPL)

Front 20

The amount of the SSI payment is the difference between the Federal Benefit Rate and the person’s

Back 20

Countable income

Front 21

The Medicaid program is administered by

Back 21

CMS

Front 22

Title XIX of the Social Security Act requires that for a state to receive federal matching funds in its Medicaid program, certain basic services must be offered called

Back 22

Mandated services

Front 23

Medically needy individuals can reduce their assets to the Medicaid eligibility level by deducting medical expenses; this is called a

Back 23

Spend down

Front 24

A commercial insurer contracted by the Dept of Health and Human Services (HHS) for the purpose of processing and administering claims is a

Back 24

Fiscal intermediary

Front 25

Individuals who receive medical assistance because their income falls within the poverty or FPL guidelines or as a result of SSI eligibility are considered

Back 25

Categorically needy

Front 26

The acronym for the program that provides comprehensive alternative care for non-institutionalized elderly persons who otherwise would be in a nursing home is

Back 26

PACE

Front 27

As a general rule, Medicaid pays only for services that are

Back 27

Medically necessary

Front 28

Before providing services to patients claiming to be on Medicaid, the health insurance professional should

Back 28

Verify eligibility

Front 29

An individual who is eligible for both Medicare and Medicaid programs is said to be a

Back 29

Dual eligible

Front 30

When an individual is covered under both Medicaid and Medicare and a private health care policy, the payer of last resort is always

Back 30

Medigap

Front 31

When one state allows Medicaid beneficiaries to be treated in an adjacent state, it is referred to as

Back 31

Reciprocity

Front 32

When a Medicaid beneficiary has no other health care coverage the type of claim to be submitted is called a ____________ claim

Back 32

Medicaid simple

Front 33

In which century did worker’s compensation get its start?

Back 33

1800's

Front 34

Companies pay premiums for workers’ compensation insurance; in return their employees agree to

Back 34

Give up the right to sue employers for on the job injuries

Front 35

Worker’s compensation is considered a

Back 35

Legally mandated right

Front 36

The Federal Employment Compensation Act (FECA) provides worker’s compensation for __________________ employees

Back 36

Non-military federal

Front 37

Which act provides workers’ compensation to employees of private maritime employers?

Back 37

Longshore and Harbor Workers’ Compensation Act

Front 38

The time limit for filing a workers’ compensation claim is established by

Back 38

The individual state statutes

Front 39

Which of the following employers are not required to provide workers’ compensation insurance to their employees?

Back 39

Employers with fewer than 3 full-time employees, individuals who are business partners, and volunteers

Front 40

Workers’ compensation insurance is considered “no-fault” insurance; this means

Back 40

Benefits are paid regardless of who is to blame for the injury

Front 41

Most state laws exclude coverage for injuries sustained while an employee is commuting to and from work. This is referred to as the

Back 41

Coming-and-going rule

Front 42

An individual responsible for investigating and resolving workers’ complaints against the employer is called a

Back 42

Personal claims representative

Front 43

What is the first step an employee should take for a first report for a non-emergency on-the-job injury?

Back 43

Complete an initial accident report

Front 44

The condition at which the employee has reached a state of maximal medical improvement is called

Back 44

Permanent and stationary

Front 45

A maximum benefit amount paid for short-term disability policies is called a _________ cap

Back 45

Benefit

Front 46

A detailed and comprehensive questionnaire that establishes financial need is a

Back 46

Financial means test

Front 47

Which of the following is not one of the responsibilities of the health insurance professional?

Back 47

Filling out the necessary forms for the patient