Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan’s
Four types of APCs are ancillary APCs, medical APCs, significant procedure APCs, and surgical APCs. An example of a type of APC known as
In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it
The Portway Hospital is qualified to receive Medicaid subsidy payments as a disproportionate share hospital (DHS). The DHS payments that Portway receives are
The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating Brice’s desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it
The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:
• Brian Pollard received treatment for a torn retina he suffered as a result of an accident
• Angelica Herrera received a general eye examination to test her vision
• Megan Holtz received medical services for glaucoma
Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:
The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
Qualitative measures that Azure could use to assess provider performance include an evaluation of how
From the following answer choices, choose the term that best matches the description.
Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.
Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.
These activities include
The following statements are about the specialist component of a provider panel. Select the answer choice containing the correct statement.
TESTED 22 Feb 2025
