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Chapter 3 - Health Ins & Claims

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Question
Answer
show managed health care (managed care)  
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Managed care is currently being challenged by the growth of what?   show
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show fee-for-service  
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Plan which reimburse providers for indiidual healthcare services rendered.   show
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show primary care provider (PCP)  
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show utilization management (utilization review)  
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show prospective review  
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Reviewing appropriateness and necessity of care provided to patients after the administration of care.   show
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show preadmission certification (PAC)  
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Review that grants prior approval for reimbursement of a healthcare service (e.g., elective surgery).   show
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Review for medical necessity of tests and procedures ordered during an inpatient hospitalization.   show
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Involves arranging appropriate healthcare services for the discharged patient (e.g., home health care).   show
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show case management  
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Responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system.   show
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An entity that establishes a utilization management program and performs external utilization review services.   show
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show second surgical opinion (SSO)  
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Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.   show
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show physician incentives  
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show physican incentive plan  
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show exclusive provider organization (EPO); integrated delivery system (IDS); health maintenance organization (HMO); point-of-service plan (POS); preferred provider organization (PPO); triple option plan  
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Managed care plan that provides benefits to subscribers who are required to receive services from netowrk providers.   show
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show integrated delivery system (IDS)  
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show health maintenance organization (HMO)  
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Patients have freedom to use the managed panel of providers or to self-refer to non-managed care providers.   show
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show preferred provider organization (PPO)  
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Usually offered either by a single insurance plan or as a joint venture among two or more insurance payers, provides subscribers or employees with a choice of HMO< PPO, or traditional health insurance plans.   show
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Healthcare plan that encourages individuals to locate the best health care at the lowest possible price, with the goal of holding down costs; also called consumer-directed health plan.   show
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show accreditation  
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show National Committee for Quality Assurance (NCQA)  
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show up-to-date lists of special administrative procedures required by each managed care plan contract.  
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show health savings account (HSA)  
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Employees and dependents who join a managed care plan.   show
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Person in whose name the insurance policy is issued.   show
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