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Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a
A. lead agent
B. beneficiary services representative
C. health plan support contractor
D. primary care manager (PCM)
As a follow-up to a performance improvement plan for member services, the Stellar Health Plan conducted an evaluation of the success of the plan. Stellar conducted its evaluation as the plan was being carried out. The evaluation focused on specific activities and assessed the relative importance of those activities to the plan as a whole. This information indicates that Stellar’s evaluation of the plan was both
A. concurrent and formative
B. concurrent and summative
C. retrospective and formative
D. retrospective and summative
Maxwell Midler’s health plan operates a drug formulary that includes a typical three-tier copayment structure with required copayments of $5, $10, and $25. Mr. Midler recently filled a prescription for a $75 drug that was not included in the formulary. According to the plan’s formulary copayment structure, the amount that Mr. Midler was required to pay for his prescription was
The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacksFrom the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-
A. Measure 1-true outcome measure Measure 2-true outcome measure
B. Measure 1-true outcome measure Measure 2-intermediate outcome measure
C. Measure 1-intermediate outcome measure Measure 2-true outcome measure
D. Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure
The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
A. An health plan's CRPs reduce the likelihood of errors in decision making.
B. CRPs typically provide for at least two levels of appeal for formal appeals.
C. CRPs include only formal appeals and do not apply to informal complaints.
D. Most complaints are resolved without proceeding through the entire CRP process.