AHM-530 | A Review Of Best Quality AHM-530 Training

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The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:
•Brian Pollard received treatment for a torn retina he suffered as a result of an accident
•Angelica Herrera received a general eye examination to test her vision
•Megan Holtz received medical services for glaucoma
Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:

  • A. M
  • B. Pollard, M
  • C. Herrera, and M
  • D. Holtz
  • E. M
  • F. Pollard and M
  • G. Herrera only
  • H. M
  • I. Pollard and M
  • J. Holtz only
  • K. M
  • L. Herrera and M
  • M. Holtz only

Answer: C


The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

  • A. A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.
  • B. A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.
  • C. One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.
  • D. One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer: B


The Blanchette Health Plan uses a method of claims submission that allows its providers to submit claims directly to Blanchette through a computer application-to-application exchange of claims using a standard data format. This information indicates that Blanchette allows its providers to submit claims using technology known as

  • A. Telemedicine
  • B. An electronic referral system
  • C. Electronic data interchange
  • D. Encounter reporting

Answer: C


The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

  • A. The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity.
  • B. Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services.
  • C. One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity.
  • D. When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

Answer: D


The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

  • A. Case mix analysis
  • B. Outcomes research
  • C. Benchmarking
  • D. Provider profiling

Answer: C


The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

  • A. limit the size of its network to the number of providers necessary to meet the needs of its enrollees
  • B. require providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate
  • C. refuse payment to non-network providers who submit claims for Medicare-coveredexpenses
  • D. shift all risk for Medicare-covered services to network providers

Answer: B


The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:

  • A. A business confidentiality clause.
  • B. A scope of services clause.
  • C. An informed refusal clause.
  • D. An exculpation clause.

Answer: D


The following statement(s) can correctly be made about the TRICARE managed healthcare program of the U.S. Department of Defense.
* 1. Active-duty military personnel are automatically enrolled in TRICARE’s HMO option (TRICARE Prime).
* 2. Eligible family members and dependents can enroll in TRICARE Prime, the PPO plan (TRICARE Extra), or an indemnity plan (TRICARE Standard).

  • A. Both 1 and 2
  • B. 1 only
  • C. 2 only
  • D. Neither 1 nor 2

Answer: A


The Ionic Group, a provider group with 10,000 plan members, purchased for its hospital risk pool aggregate stop-loss insurance with a threshold of 110% of projected costs and a 10% coinsurance provision. Ionic funds the hospital risk pool at $40 per member per month (PMPM).
If Ionic’s actual hospital costs are $5,580,000 for the year, then, under the aggregate stop- loss agreement, the stop-loss insurer is responsible for reimbursing Ionic in the amount of

  • A. $30,000
  • B. $270,000
  • C. $300,000
  • D. $702,000

Answer: B


Health plans typically conduct two types of reviews of a provider's medical records: an evaluation of the provider's medical record keeping (MRK) practices and a medical record review (MRR). One true statement about these types of reviews is that:

  • A. An MRK covers the content of specific patient records of a provider.
  • B. The NCQA requires an examination of MRK with all of a health plan's office evaluations.
  • C. An MRR includes a review of the policies, procedures, and documentation standards the provider follows to create and maintain medical records.
  • D. The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's network.

Answer: A


One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

  • A. ERISA applies to all issuers of health insurance products, such as HMOs
  • B. pension plans and employee welfare plans are exempt from any regulation under ERISA
  • C. ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans
  • D. the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans

Answer: D


The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

  • A. Potential providers in a plan’s network to the number of individuals in the area to be served by the plan
  • B. Providers in a plan’s network to the number of enrollees in the plan
  • C. Providers outside a plan’s network to the number of providers in the plan’s network
  • D. Support staff in a plan’s network to the number of medical practitioners in the plan’s network

Answer: B


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.
In most states, a health plan can be held responsible for a provider’s negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements,marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).

  • A. Vicarious liability / employees of the health plan
  • B. Vicarious liability / independent contractors
  • C. Risk sharing / employees of the health plan
  • D. Risk sharing / independent contractors

Answer: B


One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

  • A. Provides the lowest level of cost for the health plan
  • B. Most closely represents what pharmacies are actually charged for prescription drugs
  • C. Offers the best control over multiple-source pharmaceutical products
  • D. Is the least expensive pricing system for the health plan to implement

Answer: A


Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

  • A. Amember’s reaction to services received during a specific encounter
  • B. The reactions of specific subsets of the health plan’s membership
  • C. Members’ positive and negative experience with the plan’s services
  • D. All of the above

Answer: D


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