The questions for this exam were last updated on January 7, 2026
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A public employer, such as a municipality or county government would be considered which of the following?
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Question No. 2
The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle, Oriole pays Isle
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Question No. 3
Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl
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Question No. 4
The following statements are about the make-up and function of an HMO's board of directors. Select the answer choice that contains the correct statement.
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Question No. 5
Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is that
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Question No. 6
General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network include A,
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Question No. 7
The following statement(s) can correctly be made about the characteristics of reports that should be provided to managers for use in managing a healthcare delivery system:
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Question No. 8
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
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Question No. 9
The criteria used to identify and measure healthcare quality are generally divided into three categories: structure, process, and outcomes measures. Structure measures, which relate to the nature and quality of the resources that a health plan has available
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Question No. 10
The following statements describe corporate transactions: Transaction A – An MCO acquired another MCO. Transaction B – A group of providers formed an organization to carry out billings, collections, and contracting with MCOs for the entire group of provide
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Question No. 11
Mr. George Bush is covered by a PBM plan that uses a closed formulary. This indicates that
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Question No. 12
In claims administration terminology, a claims investigation is correctly defined as the process of
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Question No. 13
Wellborne HMO provides health-related information to its plan members through an Internet Web site. Laura Knight, a Wellborne plan member, visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option
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Question No. 14
One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it
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Question No. 15
The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. One key difference is that