QUESTION: 57

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

True
False

Answer(s): A

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An health plan's contract negotiation team consists of several skilled individuals from different areas. At least one of the members is responsible for evaluating the wording of specific clauses to ensure that the health plan's rights are protected, as well as to ensure that the contract is in compliance with state and federal regulation. By profession, this member of the contract negotiation team is typically

Amedical director
An attorney
Afinancial manager
Aclaims manager

Answer(s): B

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QUESTION: 59

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.
In general, the ideal negotiating style for provider contracting is a collaborative approach.
Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.
The actual signing of the provider contract typically takes place after negotiations are completed.

Answer(s): C

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QUESTION: 60

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

Typically, health plans are required to pay completed claims within 10 days of submission. 26
Health plans typically are prohibited from examining the financial soundness of a self-funded employer plan that relies on the health plan to pay providers for services received by the plan's members.
Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for-service (FFS) basis.
Health plans require all providers to agree to an exclusive provider contract.

Answer(s): C

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