How Many Questions Of AHM-530 Actual Test

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NEW QUESTION 1

To protect providers against business losses, many health plan-provider contracts include carve-out provisions to help providers manage financial risk. The following statements are examples of such provisions:
The Apex Health Plan carves out immunizations from PCP capitations. Apex compensates PCPs for immunizations on a case rate basis.
The Bengal Health Plan carves out behavioral healthcare services from the scope of PCP services because these services require specialized knowledge and skills that most PCPs do not possess.
From the answer choices below, select the response that best identifies the types of carve- outs used by Apex and Bengal.

  • A. Apex: disease-specific carve-out Bengal: specialty services carve-out
  • B. Apex: disease-specific carve-out Bengal: specific-service carve-out
  • C. Apex: specific-service carve-out Bengal: specialty services carve-out
  • D. Apex: specific-service carve-out Bengal: disease-specific carve-out

Answer: C

NEW QUESTION 2

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This reportincluded such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:

  • A. An encounter report
  • B. An external standards report
  • C. Aprovider profile
  • D. An access to care report

Answer: C

NEW QUESTION 3

Determine whether the following statement is true or false:
The NCQA has established a Physician Organization Certification (POC) program for the purpose of certifying medical groups and independent practice associations for delegation of certain NCQA standards, including data collection and verification for credentialing and recredentialing.

  • A. True
  • B. False

Answer: A

NEW QUESTION 4

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

  • A. Atermination with cause clause
  • B. Ahold-harmless clause
  • C. An indemnification clause
  • D. Acorrective action clause

Answer: B

NEW QUESTION 5

The sizes of the businesses in a market affect the types of health programs that are likely to be purchased. Compared to smaller employers (those with fewer than 100 employees), larger employers (those with more than 1,000 employees) are

  • A. more likely to contract with indemnity health plans
  • B. more likely to offer their employees a choice in health plans
  • C. less likely to contract with health plans
  • D. less likely to require a wide variety of benefits

Answer: B

NEW QUESTION 6

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 requires health plans to meet minimum performance standards outlined in a state's request for proposal (RFP)
  • B. Open contracting makes it possible for the Medicaid agency to offer enrollment volume guarantees
  • 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

Answer: D

NEW QUESTION 7

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

NEW QUESTION 8

One important aspect of network management is profiling, or provider profiling. Profiling is most often used to

  • A. measure the overall performance of providers who are already participants in the network
  • B. assess a provider’s overall satisfaction with a plan’s service protocols and other operational areas
  • C. verify a prospective provider’s professional licenses, certifications, and training
  • D. familiarize a provider with a plan’s procedures for authorizations and referrals

Answer: A

NEW QUESTION 9

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:

  • A. $200
  • B. $1,000
  • C. $1,800
  • D. $9,000

Answer: C

NEW QUESTION 10

The following statements are about managed dental care. Three of these statements are true, and one is false. Select the answer choice containing the FALSE statement.

  • A. Managed dental care is federally regulated.
  • B. Dental HMOs typically need very few healthcare facilities because almost all dental services are delivered in an ambulatory care setting.
  • C. Currently, there are no nationally recognized standards for quality in managed dental care.
  • D. Processes for selecting dental care providers vary greatly according to state regulationson managed dental care networks and the health plan’s standards.

Answer: A

NEW QUESTION 11

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

NEW QUESTION 12

The following situations illustrate violations of federal antitrust laws:
Situation A Two HMOs split a large employer group by agreeing to let one HMO market to some company employees and to let the second HMO market to different company employees.
Situation B Members of a physician-hospital organization (PHO) that has significant market share jointly agreed to exclude a physician from joining the PHO solely because that physician has admitting privileges at a competing hospital.
From the following answer choices, select the response that best identifies the types of violations illustrated by these situations:

  • A. Situation A: horizontal division of territories; Situation B: group boycott
  • B. Situation A: horizontal division of territories; Situation B: exclusive arrangement
  • C. Situation A: exclusive arrangement; Situation B: group boycott
  • D. Situation A: exclusive arrangement; Situation B: tying arrangement

Answer: A

NEW QUESTION 13

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

NEW QUESTION 14

The Elizabethan Health Plan uses a direct referral program, which means that

  • A. PCPs in Elizabethan’s network can make most referrals without obtaining prior authorization from Elizabethan
  • B. PCPs in Elizabethan’s network must always refer plan members to other specialists within the network
  • C. Elizabethan’s plan members can bypass the PCP and obtain medical services from a specialist without a referral
  • D. Elizabethan’s plan members must obtain referrals directly from Elizabethan

Answer: A

NEW QUESTION 15

In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:

  • A. making generic substitutions of drugs
  • B. counseling patients about prescriptions
  • C. providing patient monitoring
  • D. switching prescription drugs to preferred drugs

Answer: B

NEW QUESTION 16
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