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CMOM Module 5| with Questions & Correct Verified Answers
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CMOM Module 5| with Questions &Correct Verified Answers
fee for service - ✔pays a discounted fee for each service rendered. Physician agrees to
provide a specific service for a fee lower than his/her regular charge
referral - ✔the procedure by which a physician obtains the approval of the payer to send
a patient to another physician or health care professional
authorization - ✔approval for services, including diagnostic services and inpatient
or outpatient treatment
concurrent review - ✔involves the ongoing evaluation of treatment for appropriateness
and necessity during the course of that treatment
retrospective review - ✔occurs after the treatment has been rendered to ensure
if appropriate care was rendered to the patient and thus proper payment
provider relations - ✔individual who is a liaison between the physician's office and the plan
Hold Harmless - ✔the patient is held harmless financially if the plan goes bankrupt and
the plan is held harmless for outcomes due to treatment decisions made by the provider
, Risk Pool - ✔withholds part of the capitation payments to physicians to cover greater
than expected expenses for referrals, hospitalizations, etc.
Reinsurance - ✔purchased by the primary insurers to protect agains excessive claim losses
stop loss insurance - ✔covers the medical expenses that exceed a certain amount per patient
patient coverage verification - ✔must be completed each time a service is performed
Copay Collection - ✔should be completed before the patient receives services
Appropriate treatment for illness - ✔treating the patient in a manner to prevent
acute occurrences and to keep the patient out of the hospital
SOAP stands for - ✔Subjective, Objective, Assessment and Plan
Communication methods with patient - ✔Website, portal, brochure, email, texts and
Limited English Proficiency (LEP)
MCO Coordinator functions - ✔1) Patient training and
education 2)HMO intermediary
3)Hospitalization approvals and discharge planning
4) coordinating referrals
5)patient satisfaction surveys
6)coordinating with physician in utilization review committee
7)coordinating quality assurance data needed by MCO or other regulatory agency
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