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47 Cards in this Set
- Front
- Back
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.
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Managed
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Individuals who are members of a managed care plan are commonly referred to as
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Enrollees
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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
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PPO
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A specific provider who oversees the total health care treatment of an individual enrolled in certain managed care plans is a
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Primary care physician
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A relatively small out-of-pocket dollar amount that a member of a managed care plan typically pays up front is called
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A co-payment
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A health care provider trained in a specific medical specialty is a
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Specialist
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A multi-specialty practice in which health care services are provided within the building complex owned by the health maintenance organization (HMO) is a
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Staff model
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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
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IPA
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An advantage of managed care organizations (MCO) is at their aim is to keep their enrollees healthy, which is commonly referred to as
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Preventive care
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A private, non-profit organization that accredits health care plans based on evaluation of the quality of care given to plan members is the
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NCQA
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An independent, not-for-profit organization that sets standards for health care in the United States and accredits most major hospitals is the
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JCAHO
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The formal term for a written complaint submitted by an individual covered by a special plan or policy is
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Grievance
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A system designed to determine the medical necessity and appropriateness of a requested medical service or procedure is a
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Utilization review
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A procedure required by most health care plans before a provider carries out specific procedures or treatment is a
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Pre-authorization
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A request by a health care provider for his or her patient to be evaluated or treated by a specialist is known as a
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Referral
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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
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HIPAA
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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
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Medicaid
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The acronym for the Medicaid program that was formerly referred to as AFDC is
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TANF
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To qualify for supplemental security income (SSI), individuals must meet certain guidelines set for by
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The federal poverty level (FPL)
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The amount of the SSI payment is the difference between the Federal Benefit Rate and the person’s
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Countable income
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The Medicaid program is administered by
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CMS
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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
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Mandated services
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Medically needy individuals can reduce their assets to the Medicaid eligibility level by deducting medical expenses; this is called a
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Spend down
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A commercial insurer contracted by the Dept of Health and Human Services (HHS) for the purpose of processing and administering claims is a
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Fiscal intermediary
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Individuals who receive medical assistance because their income falls within the poverty or FPL guidelines or as a result of SSI eligibility are considered
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Categorically needy
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The acronym for the program that provides comprehensive alternative care for non-institutionalized elderly persons who otherwise would be in a nursing home is
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PACE
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As a general rule, Medicaid pays only for services that are
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Medically necessary
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Before providing services to patients claiming to be on Medicaid, the health insurance professional should
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Verify eligibility
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An individual who is eligible for both Medicare and Medicaid programs is said to be a
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Dual eligible
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When an individual is covered under both Medicaid and Medicare and a private health care policy, the payer of last resort is always
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Medigap
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When one state allows Medicaid beneficiaries to be treated in an adjacent state, it is referred to as
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Reciprocity
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When a Medicaid beneficiary has no other health care coverage the type of claim to be submitted is called a ____________ claim
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Medicaid simple
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In which century did worker’s compensation get its start?
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1800's
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Companies pay premiums for workers’ compensation insurance; in return their employees agree to
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Give up the right to sue employers for on the job injuries
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Worker’s compensation is considered a
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Legally mandated right
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The Federal Employment Compensation Act (FECA) provides worker’s compensation for __________________ employees
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Non-military federal
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Which act provides workers’ compensation to employees of private maritime employers?
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Longshore and Harbor Workers’ Compensation Act
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The time limit for filing a workers’ compensation claim is established by
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The individual state statutes
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Which of the following employers are not required to provide workers’ compensation insurance to their employees?
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Employers with fewer than 3 full-time employees, individuals who are business partners, and volunteers
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Workers’ compensation insurance is considered “no-fault” insurance; this means
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Benefits are paid regardless of who is to blame for the injury
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Most state laws exclude coverage for injuries sustained while an employee is commuting to and from work. This is referred to as the
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Coming-and-going rule
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An individual responsible for investigating and resolving workers’ complaints against the employer is called a
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Personal claims representative
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What is the first step an employee should take for a first report for a non-emergency on-the-job injury?
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Complete an initial accident report
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The condition at which the employee has reached a state of maximal medical improvement is called
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Permanent and stationary
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A maximum benefit amount paid for short-term disability policies is called a _________ cap
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Benefit
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A detailed and comprehensive questionnaire that establishes financial need is a
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Financial means test
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Which of the following is not one of the responsibilities of the health insurance professional?
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Filling out the necessary forms for the patient
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