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The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

  • A. Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates D
  • B. Quill’s contract without cause
  • C. Requires that Regal must base its decision to terminate D
  • D. Quill’s contract on clinical criteria only
  • E. Allows either Regal or D
  • F. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process
  • G. Allows Regal to terminate D
  • H. Quill’s contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

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 Aztec Health Plan has a variety of organizational committees related to quality and utilization management. These committees include the medical advisory committee, the credentialing committee, the utilization management committee, and the quality management committee. Of these committees, the one that most likely is responsible for providing oversight of Aztec's inpatient concurrent review process is the:

  • A. medical advisory committee
  • B. credentialing committee
  • C. utilization management committee
  • D. quality management committee

Answer: C


From the following answer choices, choose the type of clause or provision described in this situation.
The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

  • A. Cure provision
  • B. Hold-harmless provision
  • C. Evergreen clause
  • D. Exculpation clause

Answer: C


The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan’s participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot’s comprehensive provider contracts. The following statements are about Dr. Zorn’s provider contract. Select the answer choice containing the correct statement.

  • A. All statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.
  • B. Because the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.
  • C. Because the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives D
  • D. Zorn advance notice of its intent to amend the contract.
  • E. Areas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.

Answer: B


The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

  • A. Typically, health plans are required to pay completed claims within 10 days of submission.
  • B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
  • C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
  • D. Health plans require all providers to agree to an exclusive provider contract.

Answer: C


The Holiday Health Plan is preparing to enter a new market. In order to determine the optimal size of its provider panel in the new market, Holiday is conducting a competitive analysis of provider networks of the market’s existing health plans. Consider whether, in conducting its competitive analysis, Holiday should seek answers to the following questions:
Question 1: What are the cost-containment strategies of the health plans with increasing market shares?
Question 2: What are the premium strategies of the health plans with large market shares?
Question 3: What are the characteristics of health plans that are losing market share?
In its competitive analysis, Holiday should most likely obtain answers to questions

  • A. 1, 2, and 3
  • B. 1 and 2 only
  • C. 1 and 3 only
  • D. 2 and 3 only

Answer: A


The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

  • A. A small health plan needs fewer physicians per 1,000 than does a large plan.
  • B. A closely managed health plan requires fewer providers than does a loosely managedplan.
  • C. Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.
  • D. Medicare products require fewer providers than do employer-sponsored plans of the same size.

Answer: B


If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as

  • A. Subrogation
  • B. Partial capitation
  • C. Coordination of benefits
  • D. Aremedy provision

Answer: A


The Festival Health Plan is in the process of recruiting physicians for its provider network. Festival requires its network physicians to be board certified. The following individuals are provider applicants whose qualifications are being considered:
Applicant 1 has completed his surgical residency, and he recently passed a qualifying examination in his field.
Applicant 2 has completed her residency in dermatology, and she is scheduled to take qualifying examinations in the next Six months.
Applicant 3 completed his residency in pediatric medicine six years ago, but he has not yet passed a qualifying examination in his field.
With regard to these applicants, it can correctly be stated that only

  • A. Applicants 1 and 2 are board certified
  • B. Applicants 2 and 3 are board certified
  • C. Applicant 1 is board certified
  • D. Applicant 3 is board certified

Answer: C


Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by

  • A. Maximizing the effects of cost shifting
  • B. Eliminating the need for utilization management
  • C. Requiring members to use separate points of entry for job-related and non-job related services
  • D. Combining administrative services for workers’ compensation and non-workers’ compensation healthcare and disability coverage

Answer: D


From the following answer choices, choose the type of clause or provision described in this situation.
The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member’s medical care on the provider.

  • A. Cure provision
  • B. Hold-harmless provision
  • C. Evergreen clause
  • D. Exculpation clause

Answer: D


When the Rialto Health Plan determines which of the emergency services received by its plan members should be covered by the health plan, it is guided by a standard which describes emergencies as medical conditions manifesting themselves by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy. This standard, which was adopted by the NAIC in 1996, is referred to as the

  • A. medical necessity standard
  • B. prudent layperson standard
  • C. “all-or-none” standard
  • D. reasonable and customary standard

Answer: B


The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

  • A. The standard fees of indemnity health insurance plans, adjusted by region
  • B. The Medicare fee schedules used by other health plans, adjusted by region
  • C. Whichever amount is higher, the billed charge or the DFFS amount
  • D. Whichever amount is lower, the billed charge or the DFFS amount

Answer: D


The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon’s employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

  • A. a carrier guarantee arrangement
  • B. open access
  • C. total replacement coverage
  • D. selective contract coverage

Answer: C


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