AHM 250 INTRODUCTION TO HEALTH MANAGEMENT (21-24)
QUESTIONS AND ANSWERS
Ethics - CORRECT ANSWER✅✅are the principles and values that guide the actions of an individual or a
population when faced with questions of right and wrong.
Truth-telling and promise-keeping. - CORRECT ANSWER✅✅Health plans and their providers must
present information honestly and honor commitments.
TRICARE - CORRECT ANSWER✅✅is the U.S. Department of Defense healthcare plan, serving members
of the military and other uniformed services of the U.S. government, retirees, and their spouses and
dependents. TRICARE uses a worldwide system of military hospitals and clinics as its main healthcare
delivery system, but this is augmented by a network of civilian providers and facilities. TRICARE provides
coverage to nearly 10 million people.
Workers' compensation - CORRECT ANSWER✅✅is a state-mandated insurance program that provides
benefits to cover healthcare costs and lost earnings for employees who suffer a work-related injury or
illness.
The Federal Employees Health Benefits (FEHB) Program - CORRECT ANSWER✅✅provides health
coverage for full-time employees of the United States government, qualified retirees, and their spouses,
dependents, and survivors.
PACE (Program of All-Inclusive Care for the Elderly). - CORRECT ANSWER✅✅It provides community-
based long-term care at a capitated rate to frail persons age 55 and older who would otherwise need
nursing home care. While some services are available in an individual's home, most are provided at an
adult day center. However, although PACE is a widely praised model, total enrollment is extremely small
(less than 16,000 nationwide, half of this in only five states.
premium assistance. - CORRECT ANSWER✅✅. Persons who qualify for Medicaid or CHIP but who also
have access to employer-sponsored health insurance enroll in the employer plan, and the state pays the
premium. Often the premium for family members not eligible for Medicaid or CHIP is also paid. The
state pays cost-sharing (deductibles, coinsurance, and copayments) for Medicaid-eligibles; CHIP-eligibles
may have to pay some cost-sharing themselves, depending on their income. Finally, the state provides
wrap coverage
,Quality Standards - CORRECT ANSWER✅✅Another change made by the BBA was the establishment of
quality standards and recipient protections for Medicaid health plans. These require plans to:
• demonstrate adequate capacity and services,
• meet certain quality assurance standards,
• assure coverage of emergency services,
• have a grievance process in place, and
• ensure that mechanisms are in place to assess the quality and appropriateness of care to enrollees
with special healthcare needs.
claim - CORRECT ANSWER✅✅is a request to an insurer or health plan for payment of benefits.
it usually takes the form of an itemized statement of healthcare services delivered by a healthcare
provider to a covered person, along with the cost of those services.
Claims administration or claims processing - CORRECT ANSWER✅✅the receiving, reviewing,
adjudicating, and paying of claims.
claimant - CORRECT ANSWER✅✅person or entity submitting a claim
adjudicate - CORRECT ANSWER✅✅a claim is to make determinations and decisions about it.)
In traditional indemnity health insurance claims is paid? - CORRECT ANSWER✅✅the provider sends a
bill to the insurer for the services delivered. The insurer processes the claim to determine if payment is
in fact due and if so pays the provider or insured.
encounter - CORRECT ANSWER✅✅is a visit by a plan member to a provider of healthcare or related
service
encounter report - CORRECT ANSWER✅✅includes the services provided, the date of service, the
diagnosis, and other information.(used when physicians are under salary or capitation)
, Providers generally transmit claims to a plan - CORRECT ANSWER✅✅by electronic data interchange
(EDI)
optical character recognition (OCR) - CORRECT ANSWER✅✅technology is used to convert printed or
even handwritten text into electronic files.
auto-adjudication - CORRECT ANSWER✅✅A database containing member profiles, member benefit
packages, provider profiles, provider compensation arrangements, and other information is either
integrated with or part of an expert software system enabling the claims system to make higher-level
claims decisions. Such a system attempts to replicate the process an expert claims examiner uses to
solve a problem to arrive at the same decision that the expert would. This process
claims administration department - CORRECT ANSWER✅✅• Data entry clerks key
• Other employees are variously called claims examiners, processors, reviewers, analysts, or
adjudicators
• Claims adjustors
• Supervisors and managers oversee the work of claims examiners, other employees, and automated
systems. They may also handle complex and large-amount claims.
claims database - CORRECT ANSWER✅✅• information on members and their covered dependents,
including date of birth, gender, and PCP;
• information on providers, including the national provider identifier (NPI), network or non-network
status, and any restrictions on the types of services a provider can perform for the plan;
• general information on provider compensation (such as fee schedules) and the specific compensation
arrangement the plan has with each provider (including risk-pooling, discounts, etc.); and
• requirements for members, including cost-sharing (deductibles, copayments, and coinsurance) and
authorization and referral requirements
Standard Claim Forms - CORRECT ANSWER✅✅Most health plans have done away with their own claims
forms and require the use of these nationally standardized forms:
• UB-04—required by the Uniform Billing Code of 2004 and used by healthcare facilities and
organizations (hospitals, clinics, home healthcare agencies, etc.).
• CMS-1500—developed by the Centers for Medicare and Medicaid Services (CMS) and used by
healthcare professionals such as physicians.
QUESTIONS AND ANSWERS
Ethics - CORRECT ANSWER✅✅are the principles and values that guide the actions of an individual or a
population when faced with questions of right and wrong.
Truth-telling and promise-keeping. - CORRECT ANSWER✅✅Health plans and their providers must
present information honestly and honor commitments.
TRICARE - CORRECT ANSWER✅✅is the U.S. Department of Defense healthcare plan, serving members
of the military and other uniformed services of the U.S. government, retirees, and their spouses and
dependents. TRICARE uses a worldwide system of military hospitals and clinics as its main healthcare
delivery system, but this is augmented by a network of civilian providers and facilities. TRICARE provides
coverage to nearly 10 million people.
Workers' compensation - CORRECT ANSWER✅✅is a state-mandated insurance program that provides
benefits to cover healthcare costs and lost earnings for employees who suffer a work-related injury or
illness.
The Federal Employees Health Benefits (FEHB) Program - CORRECT ANSWER✅✅provides health
coverage for full-time employees of the United States government, qualified retirees, and their spouses,
dependents, and survivors.
PACE (Program of All-Inclusive Care for the Elderly). - CORRECT ANSWER✅✅It provides community-
based long-term care at a capitated rate to frail persons age 55 and older who would otherwise need
nursing home care. While some services are available in an individual's home, most are provided at an
adult day center. However, although PACE is a widely praised model, total enrollment is extremely small
(less than 16,000 nationwide, half of this in only five states.
premium assistance. - CORRECT ANSWER✅✅. Persons who qualify for Medicaid or CHIP but who also
have access to employer-sponsored health insurance enroll in the employer plan, and the state pays the
premium. Often the premium for family members not eligible for Medicaid or CHIP is also paid. The
state pays cost-sharing (deductibles, coinsurance, and copayments) for Medicaid-eligibles; CHIP-eligibles
may have to pay some cost-sharing themselves, depending on their income. Finally, the state provides
wrap coverage
,Quality Standards - CORRECT ANSWER✅✅Another change made by the BBA was the establishment of
quality standards and recipient protections for Medicaid health plans. These require plans to:
• demonstrate adequate capacity and services,
• meet certain quality assurance standards,
• assure coverage of emergency services,
• have a grievance process in place, and
• ensure that mechanisms are in place to assess the quality and appropriateness of care to enrollees
with special healthcare needs.
claim - CORRECT ANSWER✅✅is a request to an insurer or health plan for payment of benefits.
it usually takes the form of an itemized statement of healthcare services delivered by a healthcare
provider to a covered person, along with the cost of those services.
Claims administration or claims processing - CORRECT ANSWER✅✅the receiving, reviewing,
adjudicating, and paying of claims.
claimant - CORRECT ANSWER✅✅person or entity submitting a claim
adjudicate - CORRECT ANSWER✅✅a claim is to make determinations and decisions about it.)
In traditional indemnity health insurance claims is paid? - CORRECT ANSWER✅✅the provider sends a
bill to the insurer for the services delivered. The insurer processes the claim to determine if payment is
in fact due and if so pays the provider or insured.
encounter - CORRECT ANSWER✅✅is a visit by a plan member to a provider of healthcare or related
service
encounter report - CORRECT ANSWER✅✅includes the services provided, the date of service, the
diagnosis, and other information.(used when physicians are under salary or capitation)
, Providers generally transmit claims to a plan - CORRECT ANSWER✅✅by electronic data interchange
(EDI)
optical character recognition (OCR) - CORRECT ANSWER✅✅technology is used to convert printed or
even handwritten text into electronic files.
auto-adjudication - CORRECT ANSWER✅✅A database containing member profiles, member benefit
packages, provider profiles, provider compensation arrangements, and other information is either
integrated with or part of an expert software system enabling the claims system to make higher-level
claims decisions. Such a system attempts to replicate the process an expert claims examiner uses to
solve a problem to arrive at the same decision that the expert would. This process
claims administration department - CORRECT ANSWER✅✅• Data entry clerks key
• Other employees are variously called claims examiners, processors, reviewers, analysts, or
adjudicators
• Claims adjustors
• Supervisors and managers oversee the work of claims examiners, other employees, and automated
systems. They may also handle complex and large-amount claims.
claims database - CORRECT ANSWER✅✅• information on members and their covered dependents,
including date of birth, gender, and PCP;
• information on providers, including the national provider identifier (NPI), network or non-network
status, and any restrictions on the types of services a provider can perform for the plan;
• general information on provider compensation (such as fee schedules) and the specific compensation
arrangement the plan has with each provider (including risk-pooling, discounts, etc.); and
• requirements for members, including cost-sharing (deductibles, copayments, and coinsurance) and
authorization and referral requirements
Standard Claim Forms - CORRECT ANSWER✅✅Most health plans have done away with their own claims
forms and require the use of these nationally standardized forms:
• UB-04—required by the Uniform Billing Code of 2004 and used by healthcare facilities and
organizations (hospitals, clinics, home healthcare agencies, etc.).
• CMS-1500—developed by the Centers for Medicare and Medicaid Services (CMS) and used by
healthcare professionals such as physicians.
