Q.
1 True or False: The No Surprises Act covers independent out-of-network lab services ordered by a
participating facility or Emergency Department of an out-of-network facility if the member has a lab
benefit. It does not take into account the participation status of the referring provider.
a. True
b. False
Ans:- a. True
Q.2 Hector is having numbness on his left side of his body and is taken to the closest Emergency
Room for treatment. The facility he is taken to stabilizes Hector but does not have the capabilities to
handle inpatient stroke patients. Hector is taken by ground ambulance to a facility that can continue
to treat his condition. Would the claim for the ground ambulance be covered as part of the Surprise
Bill Mandate?
a. Yes
b. No
Ans:- a. Yes
Q.5 Select all that apply to the Independent Dispute Resolution/Arbitration (IDR) Process Timeline
a. 30 days to negotiate
b. 4 days to submit to IDR
Ans:- a. 30 days to negotiate
Q.8 True or False: The No Surprises Act covers independent out-of-network lab services ordered by a
participating facility or Emergency Department of an out-of-network facility if the member has a lab
benefit. It does not take into account the participation status of the referring provider.
a. True
b. False
Ans:- a. True
Q.9 The Recognized Amount (RA) may be determined by...select all that apply
a. An All-Payer Model Agreement
b. The member's plan benefits
Ans:- a. An All-Payer Model Agreement
Q.10 What is the Surprise Bill Indicator (SBI) on the SCCF in Blue2 that lets the Home pian know the
claim is part of the Federal Surprise Bill for Host Plans where the Allowed Amount and the
Recognized Amount values are the same?
a. C
b. E
Ans:- b. E
Q.12 True or False: General Inquiry with the new Reason Code '331' must be sent by the Host Plan
when the Investigation Indicator is equal to 'C' and a notice of consent has been received from the
provider so the Home Plan will have it to review and validate.
a. True
b. False
Ans:- a. True
Q.13 Providers must initiate the negotiation request on the designated form that can be submitted
to...select all that apply
a. Negotiation@[Link]
b. FedSurpriseBill@[Link]
c. PO Box 820 Newark, NJ 07101
d. PO Box 317 Newark, NJ 07301
e. PO Box 106 Newark NJ 07101
Ans:- e. PO Box 106 Newark NJ 07101
Q.14 True or False: The NCompass Workbasket used for ITS Cases is
CorrProfOONConsProtectionArbitration@HZ
A. True
b. False
Ans:- b. False
Q.? Mei is having surgery to relieve a pinched nerve in her arm that her doctor has been treating for
the past year. Mei has elected to use a non-participating surgeon that a family member
recommended since she has Out-of-Network benefits under her plan. The day before the procedure
Mei signed the consent form acknowledging that the provider is Out-of-Network and can balance bill
her. Would the surgeons claim be considered under the Surprise Bill Mandate?
A. yes
B. no
Ans:- B. no
Q.? What is the segment used on the claim in NASCO to see if the claim is a Federal Surprise bill?
a. ML
b. P2
c. PN
d. M3
Ans:- M3
Q.? What is the Surprise Bill Indicator (SBI) on the claim in NASCO that indicates the claim is a Federal
Surprise Bill?
a. H
b. F
c. S
d. B
Ans:- b. F
Q.? What 2 ways can be used to determine if the ( Can’t see and scan the text)
a. RCOE c.?
b.? d. ? Ans:-???
Q.? Atan has a claim for an assistant surgeon that is Out-of-Network from a procedure he
had performed at in In-Network facility by an In-Network surgeon. Alan was not even aware
the procedure would require an assistant present and his claim has denied as he does not
have Out-of-Network coverage. Alan's claim processed on 2/1/2024 and Horizon has
received the designated request for open negotiation form on 2/20/2024 Would this case be
eligible for negotiation?
a. Yes
b. No
Ans:- a. Yes
Q.? Delivery Method is equal to 0, 1, 2, 3, 4, 5, 9, G, H, I, J, K, L, M or N? select all that apply.
a. 11017
b. IRL.7K
c. PRL7K
d. PIO17
e. CEOR
Ans:- B,C (Both)
Q.? ??????
b. The provider's contract with Horizon
c. Existing state law or regulation, or if no All-Payer Model Agreement or state law is in place
d. The lesser of the billed amount or the QPA
Ans:- C,D (Both)
