Network managers rely on a health plan's claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan's claims administration department enables the health plan to

• A. evaluate providers' practice patterns and compliance with the health plan's procedures for the delivery of care
• B. all of the above
• C. determine the number of healthcare services delivered to plan members
• D. monitor the types of services provided by the health plan's entire provider network

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plan's provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan's preestablished criteria for participation in the network.

• A. credentialing
• B. authorization
• C. utilization management
• D. provider relations

Federal laws-including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Act-have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate:
Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.
Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest.
From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based.

• A. Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA
• B. Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act
• C. Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act
• D. Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan's participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot's comprehensive provider contracts. The following statements are about Dr. Zorn's provider contract. Select the answer choice containing the correct statement.

• A. Because the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.
• B. Areas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.
• C. Because the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives Dr. Zorn advance notice of its intent to amend the contract.
• D. All statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.

One true statement about the Medicaid program in the United States is that:

• A. The individual states have responsibility for administering the Medicaid program
• B. Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending
• C. The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs
• D. Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30