NWCA study guide UPDATED ACTUAL Questions and
CORRECT Answers
Managed Care Organization (MCO) Combines functions of health insurance, delivery of care and administration
Exclusive Provider Organization (EPO) Services covered only if use doctors, specialists or hospitals in plans network
(except in hospitals)
Health Maintenance Organization (HMO) Limits coverage to care from doctors who work for or contract with the HMO,
generally won't cover out of network care except in emergency. May require to
live or work in its service area.
Point of Service (POS) Pay less if you use doctors, and other health care providers that belong to the
plans network, required to get a referral from primary care doctor in order to see
specialist
Quality Improvement Organization (QIO) Physician can hose whether or not accept Medicare patients, who are seeking
non medical services, signs an agreement and May sign a participating provider
agreement(PAR)
Preferred Provider Organization (PPO) Pay less if use providers in plans network. Can use providers outside of network
without a referral for N additional cost.
DHHS stands for Department of health and human services
Medicare Administrative Contractor (MAC) is A private health care insurer awarded geographic jurisdiction to process
medicare A y B
Medicare A covers Hospital care, skilled nursing facility care, nursing home, ( as long as custodial
care isn't the only type of care needed), hospice, o e health services
Part b covers Medically necessary services, preventative services
Part C is Medicare advantage plan, often a HMO, OR PPO, or other health plan that also
offers prescription drug coverage, get A,B, and D
When health care providers agree to accept Medicare Agree to accept MAC payment as full, called accepting assignment
reimbursement, they sign an agreement with MACs
DRG assignment A system of payment rates to health care providers in which illnesses are
categorized into related types
Medicare severity diagnosis related groups (MS-DRG) Reimbursement decisions
are used for
CORRECT Answers
Managed Care Organization (MCO) Combines functions of health insurance, delivery of care and administration
Exclusive Provider Organization (EPO) Services covered only if use doctors, specialists or hospitals in plans network
(except in hospitals)
Health Maintenance Organization (HMO) Limits coverage to care from doctors who work for or contract with the HMO,
generally won't cover out of network care except in emergency. May require to
live or work in its service area.
Point of Service (POS) Pay less if you use doctors, and other health care providers that belong to the
plans network, required to get a referral from primary care doctor in order to see
specialist
Quality Improvement Organization (QIO) Physician can hose whether or not accept Medicare patients, who are seeking
non medical services, signs an agreement and May sign a participating provider
agreement(PAR)
Preferred Provider Organization (PPO) Pay less if use providers in plans network. Can use providers outside of network
without a referral for N additional cost.
DHHS stands for Department of health and human services
Medicare Administrative Contractor (MAC) is A private health care insurer awarded geographic jurisdiction to process
medicare A y B
Medicare A covers Hospital care, skilled nursing facility care, nursing home, ( as long as custodial
care isn't the only type of care needed), hospice, o e health services
Part b covers Medically necessary services, preventative services
Part C is Medicare advantage plan, often a HMO, OR PPO, or other health plan that also
offers prescription drug coverage, get A,B, and D
When health care providers agree to accept Medicare Agree to accept MAC payment as full, called accepting assignment
reimbursement, they sign an agreement with MACs
DRG assignment A system of payment rates to health care providers in which illnesses are
categorized into related types
Medicare severity diagnosis related groups (MS-DRG) Reimbursement decisions
are used for
