Freedom Health and Optimum HealthCare Certification Practice Exam

These questions are part of the practice quiz. Start practicing

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