AHIP Medical Management - AHM-540 Exam Practice Test
The following statement(s) can correctly be made about the characteristics of peer review: 1.Peer review is applicable to either single episodes of care or to entire programs of care 2.Most peer review is conducted concurrently
3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans
3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans
Correct Answer: B
Vote an answer
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say
Correct Answer: C
Vote an answer
Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:
Provision 1-Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2-Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.
Provision 1-Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2-Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.
Correct Answer: D
Vote an answer
The BBA of 1997 allows states to provide Medicaid benefits to children through the State Children's Health Insurance Program (SCHIP). Under the terms of the BBA, states can implement SCHIP as
1.Part of their existing Medicaid programs
2.Separate commercial insurance programs
1.Part of their existing Medicaid programs
2.Separate commercial insurance programs
Correct Answer: D
Vote an answer
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.
Only physicians can make nonauthorization decisions based on medical necessity.
Correct Answer: B
Vote an answer
The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
2.The National Committee for Quality Assurance (NCQA)
3.The American Accreditation HealthCare Commission/URAC (URAC)
1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
2.The National Committee for Quality Assurance (NCQA)
3.The American Accreditation HealthCare Commission/URAC (URAC)
Correct Answer: A
Vote an answer
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to
Correct Answer: A
Vote an answer
The paragraph below contains two pairs of terms in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.
Correct Answer: B
Vote an answer
The following statement(s) can correctly be made about the scope of case management:
1.Case management incorporates activities that may fall outside a health plan's typical responsibilities, such as assessing a member's financial situation
2.Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review
3.Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs
1.Case management incorporates activities that may fall outside a health plan's typical responsibilities, such as assessing a member's financial situation
2.Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review
3.Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs
Correct Answer: B
Vote an answer
To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is
Correct Answer: A
Vote an answer
MCOs usually have a formal program for the oversight of delegated activities. The following statements concern typical delegation oversight programs. Select the answer choice containing the correct statement.
Correct Answer: D
Vote an answer
Three general categories of coverage policy-medical policy, benefits administration policy, and administrative policy-are used in conjunction with purchaser contracts to determine a health plan's coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan's
Correct Answer: D
Vote an answer