Providers
Quiz by Ashley Jones
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- Q1
A network gap is identified as:
the lack of an in-network provider within 3 miles of the member's zip code.
the lack of an in-network provider within the maximum distance requirement.
a specialty not tied to a specifically named network.
a specialty/service not covered by the assigned network.
45s - Q2
An identified provider or facility on the Preclusion List is exempt from receiving Medicare payments for 90 days from the date being added to the list.
falsetrueTrue or False45s - Q3
While on vacation in Colorado, a member fills a prescription at the CVS Pharmacy near their resort. This pharmacy will be considered out-of-network due to its location.
falsetrueTrue or False45s - Q4
If a member calls in on September 9th to change their PCP to a new provider, when will the change be effective?
October 1st
September 9th
November 1st
September 1st
45s - Q5
A member is calling on February 12th after an ER visit the night before. They were advised to follow up with their PCP within 1 week of being seen at the ER, but state they'd like to use a new PCP. What type of PCP change can we consider for the member?
Standard PCP Change
Exception to Standard PCP Change
Retroactive PCP Change
45s - Q6
A member calls on June 23rd. They are requesting to change their PCP as they would rather have a female doctor. They would like to schedule their annual wellness check-up in the fall with the new PCP. What type of PCP change will we process and what would be the effective date of the change?
Standard PCP Change; July 1
Standard PCP Change; August 1
Advise the member they will need to call back 30 days before their desired appointment to make the change.
Exception to Standard PCP Change; July 1
45s - Q7
Which command path would you enter in CSIM to change a member's PCP?
C>C>D
M>D>U>A
INQ 15
INQ 20
45s - Q8
Always offer a member at least ______ provider options, unless the caller requests otherwise.
2
5
3
4
45s - Q9
When using the NAP tool, use the member's ____________ to identify the assigned network.
county
LOB
region code
plan name
45s - Q10
Drop the provider in the correct category.
Users sort answers between categoriesSorting60s - Q11
On the NAP tool, what does Fee For Service (FFS) mean?
Shows which specialists charge CarePlus an out-of-network fee
Indicates members may incur a fee at that specialist/facility for services rendered
States that specialty/facility does not accept CarePlus
Identifies when there is no specific network attached to a specialty/facility
45s - Q12
Which STC will you use to send a member a printed Provider Directory?
Users enter free textType an Answer45s - Q13
As a best practice, you should only submit requests for a printed Provider Directory for a 15 or 30 mile radius from the member's zip code.
truefalseTrue or False45s - Q14
ICRs must advise members they will receive a printed Provider Directory in:
up to 10 business days
up to 10 calendar days
up to 14 business days
up to 6 calendar weeks
45s - Q15
ICRs must advise members they will receive their updated ID with the new PCP in:
up to 10 calendar days
30 days after the effective date
30 days before the effect date
up to 10 business days
45s