The nature of the claims function within health plans varies by type of plan and by the compensation arrangement that the plan has made with its providers. For example, it is generally correct to say that, in a
The Mirror Health Plan uses a form of computer/telephony integration (CTI) to manage telephone calls coming into its member services department. When a member calls the plan's central telephone number, a device answers the call with a recorded message and
The National Association of Insurance Commissioners' (NAIC's) Unfair Claims Settlement Practices Act specifies standards for the investigation and handling of claims. The Act defines unfair claims practices and notes that such practices are improper if the
Which facility would best meet the need of Jack who fell on road and sprained his ankle?
The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio.
According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is
The owners of an MCO typically delegate authority for governing the operation of the MCO by electing the MCO's
The following statement(s) can correctly be made about electronic data interchange (EDI):
The following statements apply to Archer medical savings accounts. Select the answer choice that contains the correct statement.
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
The agreement by two or more independent competitors on the prices or fees that they will charge for services is known as:
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