NWCA study guide/NWCA Review Exam Ques ons and
answers Newest RATED A+ NEW EDITION
Managed Care Organiza on (MCO) - Ans Combines func ons of health insurance, delivery of
care and administra on
Exclusive Provider Organiza on (EPO) - Ans Services covered only if use doctors, specialists or
hospitals in plans network (except in hospitals)
Health Maintenance Organiza on (HMO) - Ans 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) - Ans 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 Organiza on (QIO) - Ans Physician can hose whether or not accept
Medicare pa ents, who are seeking non medical services, signs an agreement and May sign a
par cipa ng provider agreement(PAR)
Preferred Provider Organiza on (PPO) - Ans Pay less if use providers in plans network. Can use
providers outside of network without a referral for N addi onal cost.
DHHS stands for - Ans Department of health and human services
Medicare Administra ve Contractor (MAC) is - Ans A private health care insurer awarded
geographic jurisdic on to process medicare A y B
, Medicare A covers - Ans 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 - Ans Medically necessary services, preventa ve services
Part C is - Ans Medicare advantage plan, o2en a HMO, OR PPO, or other health plan that also
offers prescrip on drug coverage, get A,B, and D
When health care providers agree to accept Medicare reimbursement, they sign an agreement
with MACs - Ans Agree to accept MAC payment as full, called accep ng assignment
DRG assignment - Ans A system of payment rates to health care providers in which illnesses are
categorized into related types
Medicare severity diagnosis related groups (MS-DRG) are used for - Ans Reimbursement
decisions
UB04 also called c,s-1450 is - Ans The insurance form used by inpa ent facili es for claims
submissions
Part A, covered in hospital expenses covers - Ans Semiprivate room, meals and special diets in
hospital, all medically necessary services
Part A, non covered in hospital expenses covers, - Ans Personal convenience items like slippers
or television, non medical necessary items.
answers Newest RATED A+ NEW EDITION
Managed Care Organiza on (MCO) - Ans Combines func ons of health insurance, delivery of
care and administra on
Exclusive Provider Organiza on (EPO) - Ans Services covered only if use doctors, specialists or
hospitals in plans network (except in hospitals)
Health Maintenance Organiza on (HMO) - Ans 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) - Ans 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 Organiza on (QIO) - Ans Physician can hose whether or not accept
Medicare pa ents, who are seeking non medical services, signs an agreement and May sign a
par cipa ng provider agreement(PAR)
Preferred Provider Organiza on (PPO) - Ans Pay less if use providers in plans network. Can use
providers outside of network without a referral for N addi onal cost.
DHHS stands for - Ans Department of health and human services
Medicare Administra ve Contractor (MAC) is - Ans A private health care insurer awarded
geographic jurisdic on to process medicare A y B
, Medicare A covers - Ans 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 - Ans Medically necessary services, preventa ve services
Part C is - Ans Medicare advantage plan, o2en a HMO, OR PPO, or other health plan that also
offers prescrip on drug coverage, get A,B, and D
When health care providers agree to accept Medicare reimbursement, they sign an agreement
with MACs - Ans Agree to accept MAC payment as full, called accep ng assignment
DRG assignment - Ans A system of payment rates to health care providers in which illnesses are
categorized into related types
Medicare severity diagnosis related groups (MS-DRG) are used for - Ans Reimbursement
decisions
UB04 also called c,s-1450 is - Ans The insurance form used by inpa ent facili es for claims
submissions
Part A, covered in hospital expenses covers - Ans Semiprivate room, meals and special diets in
hospital, all medically necessary services
Part A, non covered in hospital expenses covers, - Ans Personal convenience items like slippers
or television, non medical necessary items.
