Freedom Health and Optimum HealthCare Certification Practice Exam

These questions are part of the practice quiz. Start practicing

• Is it true that the plan deductible must be satisfied before preventive services are covered?
• Which resource should you use to verify whether a provider is serving as a PCP?
• Which statement is NOT true about disenrollment?
• Some plans may have narrow or select networks. With these plans, if the enrollee chooses a PCP that is part of an IPA or medical group, the specialists, ancillary providers, and hospitals available to them may be limited to only those contracted with the PCP's IPA or medical group.
• Which entity is responsible for confirming the provider's network status for potential enrollees?
• What is the purpose of an Explanation of Benefits (EOB) or remittance advice?
• What does preauthorization entail?
• Under this plan, do enrollees need a referral to see a specialist or out-of-network provider?
• Not all providers are contracted to serve as a primary care physician (PCP). Use the online tool to find/verify the PCP indicator information.
• What considerations apply to post-acute care coverage?
• What is the primary purpose of CPT coding guidelines?
• PPO plans generally involve which of the following regarding network costs?
• FWA stands for and what is included?
• What is a negotiated rate?
• What is the primary goal of Special Needs Plans?
• Carriers may not pay for prescriptions if members use an Out-Of-Network pharmacy (except in certain cases). Which choice does not represent a certain case that would allow for Out-Of-Network reimbursement?
• What is the purpose of the ANOC letter?
• PPO networks outside network will result in additional costs unless the services are classified as an emergency.
• What is a fee schedule and how does it relate to an allowed amount?
• Which choice does not represent a drug exception option?
• Credentialing and enrollment difference: which statement is true?
• Do HMO and PPO plans have basic commonalities such as eligibility criteria and rate rules?
• For a beneficiary who enrolled in an MA-only plan during the Annual Election Period, the beneficiary will not be able to enroll in a plan that offers prescription drug coverage until the following Annual Election Period. EXCEPTION: The beneficiary chooses to use their one-time election during the Open Enrollment Period or qualifies for a Special Election Period.
• What does CPT/HCPCS Modifier 59 indicate?
• Which statement best describes the type of event intended to steer enrollees toward specific plans?
• When responding to a sales misrepresentation inquiry, you should respond within the designated time frame and include any pertinent notes from your sales appointment that may apply to the allegation.
• The SEP for Enrollment into a Chronic Care SNP will apply as long as:
• Which statement is true about reporting requirements before advertising?
• A 'special needs individual' is eligible for Medicare Parts A and B.
• Which elements constitute adequate medical necessity documentation?
• Beneficiaries must be notified of cancellations or modifications by which method?
• The beneficiary must continue to pay the Medicare Part B premium to be eligible for the HMO plan.
• Which of these activities would NOT be classified as marketing misrepresentation?
• Which sources determine medical necessity criteria?
• Which items are components of patient financial responsibility?
• Which statement is NOT true about Low Income Assistance for Part D plans?
• Which statement best describes a characteristic of PPO plans?
• Define a clean claim.
• Catastrophic Coverage begins once the member reaches the TrOOP threshold.
• Which statement about interactions between MA plans and PDPs is true?
• FIDE stands for Fully Integrated Dual Eligible.
• Define coordination of benefits (COB).
• To be eligible for a Stand alone Part D plan, the enrollee must be entitled to Part A or enrolled in Part B, and reside in the drug plan's service area.
• Which term describes events designed to steer potential enrollees toward a plan or a limited set of plans?
• Which statement about reporting when events occur is true?
• During the Open Enrollment Period, a beneficiary may use their one-time election to switch plans.
• What is the role of the Privacy Officer?
• In inpatient billing, what determines reimbursement?
• Which statement is true about Medicare Advantage plans (Part C) administration?
• The Late Enrollment Penalty does not apply to LIS members or members with creditable coverage.
• ICD-10-CM stands for which of the following?
• If preventive care and screening tests are obtained from out-of-network providers, who is responsible for the costs?
• The scope of appointment is required to discuss which types of products during a PDP appointment?
• Which statement regarding eligibility criteria for Medicare Advantage HMO plans is true?
• What are remittance advice codes?
• Reviewing ANOC information with your clients helps them decide whether they may need to change plans based upon their needs.
• In plans with narrow networks, access to specialists and hospitals may be limited to those contracted with which entity?
• Which statement describes cost-sharing when using preferred pharmacies?
• If a MA-only HMO enrollee signs up for a PDP, what happens to their MA plan?
• What is the primary purpose of the HIPAA Privacy Rule?
• Which Part D benefit phase was eliminated starting with Calendar Year 2025?
• Which statement about the Open Election Period (OEP) is FALSE?
• Which statement best reflects consent requirements for TPMOs?
• Which of the following are the types of Special Needs Plans (SNPs)?
• Repeated late reporting or event cancellations may result in what outcome?
• CMS will allow Third-Party Marketing Organizations (TPMOs) to continue sharing a beneficiary's data as long as they obtain prior express written consent through a clear and conspicuous disclosure for each TPMO that will receive the beneficiary's data and contact them.
• Chronic SNPs (CSNPs) must reconfirm a beneficiary's eligibility:
• What does Assignment of Benefits (AOB) authorize?
• To be considered qualified or ready to sell, which elements are required?
• What does charge capture refer to in a billing cycle?
• Documents with beneficiary information (such as withdrawn, incomplete, or incorrect applications, or records at the end of the required retention period) must be properly disposed of via cross cut shredding and NOT reused or placed into regular recycling or trash containers.
• In coordination of benefits, which payer pays first?
• If a beneficiary currently has drug coverage through another carrier, you must verify their prescriptions would be covered under our plan's formulary, too. The drugs that are actually covered may vary from one carrier to another or one plan to another.
• Which statement about extra benefits in MA-PD plans is correct?
• MACRA's impact on Medigap plans became effective in which year?
• What elements are included in the Medicare Advantage or Part D marketing materials/sales kit?
• Prescription drug costs under Part D apply toward the medical out-of-pocket maximum.
• Marketing events must not occur within how many hours of an educational event in the same location?
• A medical emergency is defined as which of the following?
• Which is NOT considered a preventive benefit?
• ICD-10-CM stands for which of the following?
• Which statement about the HIPAA Security Rule is correct?
• How is Modifier 25 used in claims?
• What is the relationship between CPT coding and ICD-10-CM coding in a claim?
• You receive a questionnaire regarding a sales misrepresentation inquiry. You must respond within the designated time frame, addressing all concerns in the allegation and include any pertinent notes from your sales appointment, event, etc. that may apply to the allegation.
• In payer contracts, what is the 'allowed amount'?
• Agents/Brokers are allowed to offer gifts as a condition of enrollment.
• Which of the following describes eligibility for the integrated D-SNP under the 2025 SEP?
• Institutional Special Needs Plans (ISNPs) restrict enrollment to eligible individuals who, for 90 days or longer, have had or are expected to require an institutional level of care.
• Which statement about a clean claim is true?
• What does the acronym CCI Edits stand for (in medical coding)?
• What is an NPI?
• Under AOB, who is paid directly by the payer for covered services?
• What is the purpose of eligibility verification?
• FEMA disaster SEPs can be used only if members missed a valid enrollment period.
• CMS created a new monthly integrated care SEP for CY2025 to allow full dual eligible individuals to elect an integrated D-SNP; this SEP is allowed only when the individual receives Medicaid through an affiliated managed care plan.
• Which statement about creditable prescription drug coverage is true?
• Who sets CPT coding guidelines?
• When can members add or drop prescription drug coverage?
• Which is a fundamental difference between an HMO and a PPO?
• Each SNP is required to develop a Model of Care with specific goals and objectives for the population it serves.
• What are CCI Edits?
• Which term describes a non-emergency situation when you need medical care right away but not in serious danger?
• Why must ICD-10-CM codes be specific when coding diagnoses?
• Special Needs Plans are intended to provide targeted care to beneficiaries with special needs.
• Which of the following is NOT a common denial reason?
• The monthly integrated care SEP beginning in 2025 allows full dual eligible individuals to elect an integrated D-SNP if they receive Medicaid through an affiliated managed care plan.
• Which consequence is common when a claim is filed after the payer's timely filing deadline?
• What is a redetermination in the payer appeals process?
• Plans sold before an agent has completed the necessary licensing, appointment and certification will not be eligible for commission payments.
• When must events be reported to the plan?
• If a beneficiary is enrolled in a MA-only HMO and they also sign up for a PDP plan, they will be automatically dropped from their MA plan.
• Which statement about rules on rates is NOT true?
• Formularies may change from year to year, so it is important to confirm coverage and copayments each plan year.
• Which items would be considered a physical safeguard for PHI?
• How many digits are in a National Provider Identifier (NPI)?
• What is a duplicate claim?
• You MUST EXPLAIN the Part D late enrollment penalty.
• What is a claims scrubber?
• Is emergency care always considered in-network?
• Which statement about the definition of the 'same location' is true?
• What does the HIPAA Security Rule address?
• Distinguish in-network vs out-of-network providers. Which statement is true?
• Who must confirm the provider's network status for potential enrollees?
• Formularies may change from year to year; confirm coverage and copayments each plan year.
• Which statement about creditable coverage is true?
• The Summary of Benefits will list which items?
• Prior to October 15, at a Sales event you may not solicit or accept enrollment applications for the AEP.
• Does enrollment into a Medicare Supplement plan automatically disenroll a beneficiary from their Medicare Advantage Plan?
• Who typically conducts a reconsideration?
• Sales event cancellations and modifications must be reported to our plan immediately.
• Which are examples of physical safeguards for PHI?
• Which choice is not a drug tier option addressed in the presentation?
• Which statement about LEP is true?
• Which of the following could be extra benefits provided by MA-PD plans beyond traditional Medicare?
• What is a preexisting condition exclusion?
• Describe the main steps in a typical billing cycle.
• Enrollment in a D-SNP under the integrated care SEP requires Medicaid eligibility or enrollment through a managed Medicaid plan.
• Which document itemizes payments made, adjustments, and patient responsibility after a claim is processed?
• Which describes a copayment?
• Which statement accurately describes enrollment handling at sales and marketing events?
• Under the monthly integrated care SEP starting in 2025, which type of plan is eligible to elect an integrated D-SNP?
• Which statement about the Coverage Gap elimination is true?
• Which duties fall under the Privacy Officer's responsibilities?
• Which statement about a provider's network status most directly affects the payer contract rates?
• What does timely filing mean in medical billing?
• Beneficiaries do not need to pay their monthly Medicare Part B premium if they pay the premium for a Medicare Supplement plan.
• Cross-cut shredding is the required method for disposing of beneficiary information.
• What does PECOS stand for in relation to Medicare enrollment?
• Which coding system is used for reporting professional services provided by physicians?
• Members may have reduced cost-share amounts on certain formulary tiers when utilizing preferred pharmacies.
• Which option correctly defines the 'same location' for marketing and educational events?
• In PPO plans, using out-of-network for non-emergency services will generally result in higher costs.
• Which statement best describes how often LIS qualifications are reviewed?
• Who must report all events prior to advertising?
• PPO plans may or may not include Part D prescription coverage. True or False?
• To enroll in a DSNP, beneficiaries must be entitled to:
• In a PDP home appointment, what condition allows an agent to discuss an HMO product in the same meeting?
• What information is typically included in an EOB/remittance advice regarding payments?
• Prior to making an enrollment decision, beneficiaries must review and complete the pre-enrollment checklist.
• The Medicare Advantage Program, sometimes called 'Part C', combines coverage for Parts A & B benefits and is administered by private health plans.
• How do observation services differ from inpatient admission for billing?
• In health insurance, which term describes the amount the patient must pay out-of-pocket before the insurer pays benefits?
• What is PECOS used for in Medicare enrollment?
• There are differences among fraud, waste, and abuse. One of the primary differences is ________ and knowledge.
• The definition of the 'same location' for events includes which of the following?
• What is an out-of-pocket maximum?
• Which statement best describes accounts receivable follow-up?
• Special Needs Plans (SNPs) are either HMO or PPO plans, and all plans include a contracted network of providers.
• Why is provider credentialing important?
• Drug coverage across carriers may vary; plan representatives must verify coverage under the beneficiary's current formulary.
• Which statement describes Prescription Drug Plans (PDP)?
• What is a superbill?
• Who typically performs a reconsideration in payer processes?
• How does a cancellation differ from a disenrollment?
• Which statement best describes the 2025 change to the Special Election Period for Dual Eligible individuals?
• Which statement about disenrollment and cancellation is correct?
• Which statement best describes medical necessity in claims processing?
• Which statement best describes PHI?
• Which step in the billing cycle occurs immediately after claim submission?
• Which factor is NOT typically part of determining post-acute care coverage?
• ANOC stands for Annual Notice of Changes.
• Which of the following is NOT a valid reason for involuntary disenrollment?
• Open Enrollment Period allows plan changes, including MA and Part D.
• Which term describes a patient paying a percentage of covered expenses after meeting the deductible?
• Which of the following is NOT an example of an integrated D-SNP mentioned in the 2025 SEP?
• Coinsurance is defined as:
• Explain the concept of COB ordering payers.
• Which of the following is an example of post-acute care?
• FIDE (Fully Integrated Dual Eligible) plans provide complete integration of Medicare and Medicaid services within one managed care organization.
• What does PHI stand for?
• Distinguish an appeal from a reconsideration.
• What is the role of a referral?
• You MUST tell your PPO plan clients they will have to pay more when seeking non-emergent eligible services outside of the network.
• Chronic SNPs focus on individuals with chronic conditions.