Which of the following indicates that a claim file is a good ...

[DyllonKazuo]

Which of the following indicates that a claim file is a good candidate for MCM?
 
  a. Two hospital admissions in a three-year period
  b. Outpatient therapies of less than six weeks (including nursing services)
  c. Home care by an RN of more than four hours per day
  d. Skilled nursing care in an extended care facility of more than one week

Question 2

Explain the provisions and guidelines of a Basic Benefit. Give examples.
 
  What will be an ideal response?

[wtf444]

Answer to Question 1

C

Answer to Question 2

Answer:
A Basic Benefit provides a specified allowance for a certain type of service. Usually, the allowance is 100 of either usual, customary, and reasonable (UCR) (as defined by the plan) or some other amount based on the relative value study (RVS) and conversion factors.
A Basic Benefit usually has a stated policy year dollar maximum, or number of visits or treatments, or a combination of both.
For example, refer to the Ball Insurance contract under Surgical benefits. As indicated, this Basic Benefit pays 100 of the UCR allowable expenses. A maximum of 1,600 is payable under the Basic Benefits only per surgery or operative session. Any money charged in excess of either the 1,600 or the allowable amount up to the UCR amount would be covered under Major Medical subject to any limitations specified by that provision. Basic Benefits are always paid first. It is possible for a single expense to be covered under multiple Basic Benefits. In this case, the first Basic Benefit would be computed, then any excess would be allowed under any other applicable Basic Benefit, and finally any remaining amount would be considered under Major Medical.
Following are some guidelines for calculating Basic Benefits:
a. Basic Benefits are always paid first before applicable Major Medical benefits are calculated.
b. Basic Benefits are usually paid at 100 of the stated amount. Any other applicable percentage must be specifically stated in the policy.
c. Basic Benefits usually have a dollar or number limit.
d. Under a basic only plan, any amount not paid by the Basic Benefit would not be covered at all. These charges would be the patient's responsibility.

[DyllonKazuo]

Thank you

[wtf444]

No problemo