- (Topic 1)
The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

1. A. Purpose of the agreement
2. B. Manner in which the provider is to bill for services
3. C. Definitions of key terms to be used in the contract
4. D. Rate at which the provider will be compensated

Correct Answer: A

- (Topic 1)
The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

1. A. D
2. B. Kwan most likely was required to seek authorization from Poplar before performing this particular service.
3. C. D
4. D. Kwan most likely was paid on a FFS basis for providing this service.
5. E. Both A and B
6. F. A only
7. G. B only
8. H. Neither A nor B

Correct Answer: D

- (Topic 2)
Medicaid is a joint federal and state program that provides healthcare coverage for low- income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the

1. A. Federal government is responsible for making all claim payments
2. B. Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries
3. C. State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement
4. D. State governments are responsible for establishing overall regulation of the Medicaid program

Correct Answer: B

- (Topic 2)
When evaluating the success of providers in meeting standards, a health plan must make adjustments for case mix or severity. One true statement about case mix/severity adjustments is that they:

1. A. Typically are more important in measuring the performance of PCPs than they are in measuring the performance of specialists
2. B. Help compensate for any unusual factors that may exist in a provider's patient population or in a particular patient
3. C. Tend to increase the number of providers who are considered to be outliers
4. D. Allow for a more equitable comparison of data between providers of outpatient care but not providers of inpatient care

Correct Answer: B

- (Topic 1)
Provider panels can be either narrow or broad. Compared to a similarly sized health plan that uses a broad provider panel, a health plan that uses a narrow provider panel most likely can expect to

1. A. Experience higher contracting costs
2. B. Encounter increased difficulty in utilization management
3. C. Have to charge higher health plan premiums
4. D. Experience lower provider relations costs

Correct Answer: D