Georgia Navigator Practice Exam

In an Exclusive Provider Organization (EPO), what is required for out-of-network services?

1. Prior approval from the EPO

2. No approvals are necessary, out-of-network services are always covered

3. Out-of-network services incur a lower copay than in-network services

4. Use of a primary care physician is mandatory for all services

The correct answer is: Prior approval from the EPO

In an Exclusive Provider Organization (EPO), prior approval from the EPO is a requirement for out-of-network services. EPO plans are designed to provide coverage exclusively through a network of doctors and hospitals. If a member seeks services outside this network, the EPO typically does not cover those services unless they meet specific exceptions, such as medical emergencies. The need for prior approval serves to contain costs and ensure that members seek care within the established network, where negotiated rates can be applied, leading to lower overall healthcare expenses for both members and the plan. This requirement is significant because it helps enforce the plan's structure, encouraging members to utilize in-network providers for most of their healthcare needs. Other options do not align with how EPOs generally function; for instance, out-of-network services are not automatically covered without prior approval, nor do they usually offer a lower copay than in-network services. Additionally, EPOs do not typically mandate a primary care physician to manage all services, allowing flexibility within their network structures.