Certified Revenue Cycle Representative (CRCR) Practice Exam

What restriction does a managed care plan place on locations that must be used if the plan is to pay for the services provided?

1. Site-of-service limitation

2. Network provider limitation

3. Geographic service area limitation

4. Facility usage restriction

The correct answer is: Site-of-service limitation

The correct answer focuses on the concept of site-of-service limitation, which specifies that a managed care plan will only cover services provided at designated locations. This means that services must be delivered in facilities that have received pre-approval or are part of the plan’s approved network. This restriction ensures that the managed care organization can control costs, maintain quality standards, and provide services within a certain framework that aligns with the plan’s policies and contracts. When patients choose to receive care outside of these designated sites, the managed care plan may deny claims for those services, emphasizing the importance of adherence to the plan's specific location-based restrictions. This ultimately affects where members can receive care if they wish to receive full benefits under their plan. While network provider limitation refers to the requirement for patients to see providers within the managed care network, and geographic service area limitation pertains to the physical boundaries within which the plan operates, it is the site-of-service limitation that most directly addresses the restriction on locations necessary for coverage. Facility usage restriction is a more general term and could apply to a variety of contexts beyond managed care plans. Thus, the site-of-service limitation is the most precise term for the restriction described in the question.