AHIP Network Management - AHM-530 FREE EXAM DUMPS QUESTIONS & ANSWERS]

Question 1

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

A. contain a gag clause or a gag rule B. include a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan C. hold that the responsibility of the provider to deliver services is usually subject to the provider's receipt of information regarding the eligibility of the member D. include a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

Discussion 0

Correct Answer: C Vote an answer

Question 2

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
A formulary lists the drugs and treatment protocols that are considered to be the preferred therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members' prescription drugs than it would if it did not use a formulary.

A. closed / lower B. closed / higher C. open / lower D. open / higher

Discussion 0

Correct Answer: C Vote an answer

Question 3

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

A. It was established to identify and discipline medical practitioners who act unprofessionally B. It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States C. It is maintained by the individual states D. The information in the NPDB is available to the general public

Discussion 0

Correct Answer: A Vote an answer

Question 4

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

A. Receives a payment that is based on reasonable costs and reasonable charges B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO C. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care D. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits

Discussion 0

Correct Answer: D Vote an answer

Question 5

Grant Pelham is covered by both a workers' compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Mr. Pelham's group health insurance plan and workers' compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers' compensation

A. Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits B. Requires employees who suffer a work-related illness or injury to obtain care from specified network providers C. Provides reimbursement for lost wages D. Covers all injuries and illnesses, regardless of their cause

Discussion 0

Correct Answer: C Vote an answer

Question 6

The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.

A. In their contracts with health plans, managed behavioral healthcare organizations (MBHOs) usually receive delegated authority for network development and management. B. Two measures of BH quality are patient satisfaction and clinical outcomes assessments. C. Health plans generally compensate managed behavioral healthcare organizations (MBHOs) on an FFS basis. D. For a health plan, one argument in favor of contracting with a managed behavioral healthcare organization (MBHO) is that the health plan's members can gain faster access to BH care.

Discussion 0

Correct Answer: C Vote an answer

Question 7

The Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

A. the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members B. all of the above C. the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package D. the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies

Discussion 0

Correct Answer: B Vote an answer

Question 8

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

A. Specialty IPA B. Specialty network management company C. Disease management company D. Single specialty management specialist

Discussion 0

Correct Answer: C Vote an answer

Question 9

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plan's provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan's preestablished criteria for participation in the network.

A. authorization B. utilization management C. provider relations D. credentialing

Discussion 0

Correct Answer: D Vote an answer

Question 10

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

A. All of the above B. Hospital privileges of prospective providers C. Malpractice insurance on prospective providers D. Liability claims histories of prospective providers

Discussion 0

Correct Answer: A Vote an answer

Question 11

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

A. be able to select most of the physicians in the FPP B. experience limited control over utilization C. achieve the highest level of cost effectiveness possible D. achieve the most effective case management possible

Discussion 0

Correct Answer: B Vote an answer

Question 12

In most states, workers' compensation is first-dollar and last-dollar coverage, which means thatworkers' compensation programs

A. Can hold employers liable for additional amounts that result from court decisions B. Must pay 100% of work-related medical and disability expenses C. Can deny coverage for work-related illness or injury if the employer is not at fault D. Can place limits on the benefits they will pay for a given claim

Discussion 0

Correct Answer: B Vote an answer

Question 13

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

A. dental PPOs compensate dentists on a capitated basis B. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis C. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis D. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners

Discussion 0

Correct Answer: D Vote an answer

Question 14

The two basic approaches that Medicaid uses to contract with health plans are open contracting and selective contracting. One true statement about these approaches to contracting is that:

A. Open contracting makes it possible for the Medicaid agency to offer enrollment volume guarantees B. Open contracting requires health plans to meet minimum performance standards outlined in a state's request for proposal (RFP) C. Selective contracting requires any health plan that meets the state's performance standards and the federal Medicaid requirements to enter into a Medicaid contract D. Selective contracting requires health plans to bid competitively for Medicaid contracts

Discussion 0

Correct Answer: D Vote an answer