Question

multiple choice question

if the patient is part of an hmo health plan, the patient must be ______ to the pcp as of the date of service.

assigned
eligible
contracted
referred

Explanation:

Analyze HMO plan requirements

Under a Health Maintenance Organization (HMO) plan, which is a key concept in Managed Care Models, patients are required to select or be designated a Primary Care Physician (PCP). This PCP acts as the gatekeeper for the patient's healthcare services, coordinating all care and providing referrals to specialists.

Determine the correct terminology

For insurance verification and billing purposes, on the specific date of service, the patient must be officially designated or linked to that specific PCP in the insurer's database. The standard administrative term used to describe this official linkage between a patient and their designated PCP is being "assigned" to the PCP.

Evaluate the given options

• assigned: Correct. HMO plans require patients to be formally assigned to a designated PCP to receive covered services.
• eligible: Incorrect. Eligibility refers to whether the patient has active coverage under the health plan, not their specific relationship to a PCP.
• contracted: Incorrect. Providers (like the PCP) are contracted with the insurance network, not the individual patients.
• referred: Incorrect. A referral is an authorization from a PCP to see a specialist, not the relationship of the patient to the PCP itself.

Answer:

• assigned (Correct answer)
• eligible
• contracted
• referred