Quantum Health- Final Exam 2024 Questions with Complete Solutions

How long does it take for pharmacy claims to process? - Immediately (Real Time) Why would a PCP's name in PIVIT be highlighted yellow? - needs updating or verification A member calls and tells you that they were just diagnosed with a serious medical condition that will require surgery and a lot of rehab. They just want to make sure that is the best and only option that they have. What kind of point solution would you suggest for them? - Second opinion What do you call a group of doctors, hospitals, and other healthcare providers that are contracted to offer their services for a lower than usual rate - Specialty/Narrow Network What section of Smart Benefit Search would you go to in order to quote a sick office visit with a pediatrician - PCP- Office Visit What does DME stand for? - durable medical equipment In which section of SBS would you look for information on specific requirements an employee would need to satisfy in order to get a lower premium? - Incentive Management Program People who have an established relationship with a PCP spend on average ____ less on healthcare - 30 When calling the network to verify whether a provider participates to not, what are the 3 pieces of information you need to obtain before calling? - Doctor's name, Facility ( Billing address), and Tax ID What 3 pieces of information do we need to properly look up a claim - date of service, amount of claim, and provider name What are the two main functions of a TPA - Administer the plan and pay claims Why does an employer hire a network for their plan - To save money and provide services at discounted (contracted) rate When building a Pre-Determination for an office procedure, what provider will you input in the top right hand corner of the Pre-D? (Physician/Facility field of the form) - NPI for Preforming Facility What Benefit would you quote for Botox Injections - Office Surgery what kind of nurse preforms daily concurrent for inpatient members? - UR Nurse At Quantum, How many pieces of information are you required to get from the member or provider prior to giving out PHI? - 3 What benefit would you quote for a CPAP machine - Durable medical equipment What are all of the places where you can locate an EOB - -TPA (Most Accurate) -Member Website -Claims wizard On a precert, which two pieces of information make it turn green or red - Place of service & CPT Code Member is calling late on a Friday night and they tell you that they think they have pink eye but their PCP is closed for the weekend. They want to know where they can go to get treatment. What type of point solution would you look for to educate them about - Telemedicine When building a precept for an OUTPATIENT SURGERY, what are the only 2 possible correct choices for the place of service dropdown portion of the precert - Ambulatory Surgical Center [24] & OP Hospital Surgery [22E] What is a EAP - Employee Assistance Program When might an out of network pay as in exemption be approved? - No network, Emergency Situations, No control, and Glogist rule What does U and C stand for - Usual & Customary Which savings account is funded by both the employer and the member to help pay for healthcare costs - HSA- Health Savings Account