WorksheetsPhase I Assessment Prep
Total questions: 48
Worksheet time: 9mins
Which best represents FEP's Service Benefit Plan?
Fee-for-service
HSA
Health Reimbursement Plan.
Facilities that meet strict measures of qualities are designated as ___________
Blue Distinction Centers
Preferred Facilities
Blue Hospitality Centers
Which represents the fixed amount of money that is collected by the provider at the time of service?
Coinsurance
Co-pay
Deductible
Our retail pharmacy vendor is ________________
CVS/Caremark
Express Scripts
Medco
What is one of the main ways that the Basic Option is different from the Standard Option?
No Out-of-Pocket Maximum
No deductible
No Pre-existing clause
Which of the following situation would require precertification?
Inpatient admission when Medicare A is primary
Admission through the outpatient emergency department of a hospital
Admission to a hospital outside of the US
If a member sees a specialist versus a primary care physician, what would increase?
Coinsurance
Co-pay
Deductible
If a Standard option member sees a PPO dentist, would would they pay?
The difference between the fee schedule amount and maximum allowable charge (MAC)
The negotiated rate between the patient and the provider
$30 copayment
When seeing a preferred provider, does the member pay a co-pay if the service is subject to the deductible?
Yes
No
Which is an example of a basic option exception?
Non-participating specialist services when referred by a Preferred primary care physician
Services of non-participating surgeons
Special provider access situations
The difference between the plan allowance and the billed amount is ________
catastrophic protection
member liability
provider write-off
If a New York member goes to a hospital in Ohio, which plan would be responsible for processing the claim?
New York
Ohio
New York and Ohio would split the claim
Will the benefits change for a Basic Option member if they use a midwife versus a doctor to deliver their child?
Yes
No
If a Basic Option member cannot reach his/her feet, what would their responsibility be for routine foot care?
15% coinsurance after the calendar year deductible
$25 copayment
No benefit for routine foot care unless the member is under the active treatment for a metabolic or peripheral vascular disease
What happens to the deductible if FEP is secondary to Medicare?
Deductible is waived for each member with Medicare A and B primary
The deductible is not impacted
Only the policyholder's deductible is waived
If a member does not have Medicare part B, which plan would pay for an outpatient service?
FEP
Medicare part A
Medicare part B
If Medicare denies charges for a member, what will FEP pay?
FEP pays nothing if Medicare denies
100% of covered charges with a copy of denial from Medicare
115% of covered charges with a copy of denial from medicare
If a member sees an out-of-network provider on January 6, 2025, which represents the latest date a claim can be submitted for the charges?
January 6, 2025
December 31, 2025
December 31, 2026
If a member falls at Target and required medical attention, which describes the process of FEP recovering the money if Target was at fault?
Policy cancellation
Refund Recovery
Subrogation
How do we determine the primary plan for children covered under both of their parents' insurance?
The birthday rule
The plan that creates the least out of pocket expenses
Longer/shorter rule
If a member's spouse has Aetna primary for medical, but the policy does not cover dental, which plan would pay primary for dental services?
FEP
No coverage if the primary does not cover dental
Aetna
If Tom's son moves in with his mother full time, what happens to his coverage under Tom's plan?
Nothing changes
A detailed explanation of the arrangement must be provided
The son is no longer eligible under FEP
When would we cover a grandchild on the policy?
We would cover from birth through 30 days
Grandchildren are automatically covered
When the grandchild is under guardianship or foster care of the subscriber
When will we cover a member's fiancé and the fiancé's children on a policy?
Only the future spouse would qualify effective the date of marriage
Open season following the date of marriage
The fiancé and children may be added effective the date of marriage
If a member wants to know if he/she should keep FEP once they enroll in Medicare, what should you not do?
Offer to review how FEP coordinates with Medicare
Send Medicare and You brochure
Tell what your 69-year old uncle did and what you think he/she should do
When would a child be eligible to stay on a policy beyond the age of 26?
If they are a college student living a home fully supported by their parents
If they are disabled due to an automobile accident that occurred last year
If they have been mentally disabled and fully dependent on their parents since birth.
Which reason qualifies a member for a 31-day grace period?
Changing carriers
Death
Divorce
Which of these is a qualifying life event?
Self only plan subscriber's spouse diagnosed with a life threatening illness
Subscriber decides they want to switch plans in the middle of the year
Subscriber's spouse loses job and is no longer eligible under their own health coverage
How long can coverage be extended under Temporary Continuation of Coverage if a member terminates their employment with the Federal Government?
12 months
18 months
They would not be eligible
Which tool helps you determine what information you can disclose to a caller?
BlueLINK Communications & Bulletin Briefs
Enrollment Reference Guide
HIPAA Verification and Disclosure Guide
Which is considered a HIPAA level of authorization?
Authorized
Automatic
Non-Preferred
If a provider cannot validate a member, what information can be provided?
Benefit information
Member ID
SSN
Which type of representative can complete an address change for a member?
Any representative
Authorized representative
Personal representative
When does the HIPAA authority for personal representatives expire?
After 1 year
At the end of the call
Written request from the member or death of member
What can authorized representatives do on behalf of the member?
Act on the member's behalf only
Receive PHI and act on the member's behalf
Receive the member's PHI only
What is the name of the representative that can be authorized over the phone?
Inferred/Informal
None
Verbal
If your friend is a federal employee and they ask you to check on their request of adding a spouse to their plan, what should you do?
Tell them nothing
Tell them to call the number on their insurance card
Take a look and let them know the status of their request
If you get a call from a provider in a different state, what information can NOT be provided?
All levels of benefits
Eligibility
Provider network status
If a member goes to the hospital for surgery, who will bill the member?
Both the hospital and the surgeon
Only the hospital
Only the surgeon
Which would be considered a facility provider?
Independent laboratory
Hospice
Urgent Care
Which would be considered a professional provider?
Ambulatory Surgery Center
County Hospital
Independent Lab
If a member request form to be sent, will we send the form to the physical address on file?
True
False
A member requests assistance finding a preferred provider. How many providers you must provide to the member?
3
2
1
4
What is the enrollment code for PSHB Standard Self Only
104
33D
111
33A
What is the enrollment Code for FEHB Blue Focus Self Plus Family
35B
133
132
33B
T/F. Does Observation services fall under Inpatient category?
True
False
T/F. Can the provider Balanced Bill the member the difference of the contract rate and total charge?
True
False
T/F. In Member360 to check to see a member has another insurance on file you will use Special Information?
True
False
