80. All of the following apply to payment of claims on a managed care plan EXCEPT
Answer: A
The covered person normally does not receive reimbursement for the service direct from the Insurer.
In a managed care plan, reimbursement typically flows directly to the provider rather than the covered person, meaning the insured individual does not receive direct payment from the insurer.
A) the covered person normally receives reimbursement for the service direct from the Insurer
This statement is incorrect because, in managed care plans, payment is most often made directly to healthcare providers, not to the insured individuals. Consequently, covered persons do not typically receive reimbursement directly from the insurer.
B) it is generally not required that covered persons file claim forms
This statement is true within the context of managed care plans, as they usually streamline the process by managing claims internally. Therefore, covered persons often do not need to file claim forms, which supports the idea that this option does not apply to payment of claims.
C) a covered person may be responsible for an increased co-payment if they visit a non-network provider
This statement is accurate as it reflects the common structure of managed care plans. When insured individuals choose to see a non-network provider, they may incur higher out-of-pocket costs, which is a standard policy in these plans. Thus, this option does not fit the exception.
D) reimbursement may be denied if a covered person visits a specialist without a required referral
This statement correctly describes a typical requirement in managed care plans, where a referral is often needed to see a specialist. Failure to obtain a referral can result in denied reimbursement, indicating this option does not apply to the exception either.
Conclusion
Answer A is definitively the correct choice as it misrepresents the reimbursement process in managed care plans. All other options accurately describe aspects of the claims payment process in managed care, highlighting that A is the only statement that does not align with the typical functioning of such plans.