To determine the benefits payable under the COB provision, use all of the following guidelines EXCEPT:
a. Compute the normal liability (NL), both Basic and Major Medical benefits, that would be payable in the absence of Medicare (perform a line-for-line calculation).
b. Determine the amount the provider is allowed to collect.
c. Use the greater of number one or number two as the base.
d. Compare the amount paid by Medicare to the base.
(
Q. 2) The most common methods for coordinating group health plans include all of the following EXCEPT:
a. Nonduplication of Medicare
b. Maintenance of benefits
c. Out-of-state benefits
d. Medicare supplemental coverage
(
Q. 3) Identify and explain the circumstances in which separate allowances are warranted for pre-operative services.
What will be an ideal response?
(
Q. 4) What is considered a rehabilitation benefit? Explain work hardening programs and their relationship to such benefits. Discuss vocational rehab as well.
What will be an ideal response?
(
Q. 5) What happens when an MCPmember requests to see a specialist?
a. The PCP must discuss the request with the member.
b. The request is denied.
c. The request must always be in regard to hospitalization.
d. The PCP chooses the specialist.
(
Q. 6) What does ZPIC stand for?
a. Zero Program Integrity Contractor
b. Zone Processing Integrity Contractor
c. Zone Program Integrity Contractor
d. Zone Program Integrated Contractor
(
Q. 7) What is considered to be an occupational illness?
a. Sunburn while on vacation
b. Illness caused by inhaling or ingesting a hazardous agent
c. Illness taking less than one year to develop
d. Food poisoning while eating lunch with coworkers
(
Q. 8) Toward the end of an auditing phase, many companies perform an Audit of the Findings as a step before which of the following?
a. A noncompliance order is issued
b. The auditors are paid
c. A malpractice case is avoided
d. A compliance plan is created
(
Q. 9) Which of the following is a step in a second opinion process?
a. A request is made by the claims examiner for a second opinion.
b. The patient's chart remains private from the second opinion doctor.
c. An internal review is done.
d. All records are forwarded to the MCP's chief medical officer for a determination.
(
Q. 10) All of the following are part of processing an MCP claim EXCEPT:
a. Checking the member's eligibility
b. Checking the member's contract
c. Determining financial responsibility
d. Assuring a second opinion