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Ace the AHIP AHM-250 Exam: Ultimate Preparation Guide

Questions 51

In Order to act as a TPA an organization must

Options:

A.

Establish written procedures for adverse determinations and appeals

B.

Obtain a certificate of authority from the state insurance department

C.

Designating the organization as a TPA

D.

All of the above

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Questions 52

The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored

Options:

A.

anti selection

B.

cost shifting

C.

receivership

D.

underwriting

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Questions 53

The following statements are about the various Health Plan Accountability Models adopted by the NAIC.

Options:

A.

Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be required to hold covered persons harmless against provider collections and provide continued coverage for uncompleted treatment in the event of plan insolvency

B.

The Health Carrier Grievance Procedure Model Act requires all health carriers to maintain a first-level grievance review, but it does not require any second-level review

C.

According to the Health Care Professional Credentialing Verification Model Act, a health plan must select all providers who meet the plan's credentialing criteria

D.

The Quality Assessment and Improvement Model Act exempts closed plans from implementing a quality improvement program.

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Questions 54

When determining physicians' fee reimbursements, the Blossom Managed Healthcare Group assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier, as shown below:

Weighted value for service × Money

Options:

A.

discounted fee-for-service system

B.

global capitation arrangement

C.

withhold arrangement

D.

relative value scale (RVS)

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Questions 55

Common characteristics of POS products are

Options:

A.

Lack of Freedom of choice

B.

Absence of Primary care physician

C.

Cost-cutting efforts and the structure of coverage

D.

All of the above

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Questions 56

Medigap policies were standardized into ten standard benefit pl ranging from A-J by the ____

Options:

A.

Omnibus Budget Reconciliation Act (OBRA) of 1990

B.

Tax Equity & Fiscal Responsibility Act (TEFRA) of 1982

C.

Medicare Modernization Act (MMA) of 2003

D.

Balanced Budget Act (BBA) of 1997

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Questions 57

Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review?

Options:

A.

Cost per procedure

B.

Concurrent review

C.

Cost of review

D.

Access requirements

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Questions 58

In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On October 23, Holt used the following information to calculate the bed days per

Options:

A.

278

B.

397

C.

403

D.

920

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Questions 59

Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that

Options:

A.

Mr. Marak has the right to appeal to the next level if the Level One appeal upholds the original decision

B.

It requires Frazier and Mr. Marak to submit to arbitration in order to resolve the dispute

C.

It is considered to be an informal appeal

D.

It will be handled by an independent review organization (IRO)

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Questions 60

Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:

Options:

A.

Provides Ms. Giambi with healthcare coverage for any illness or injury, but only if the cause of the illness or injury is work-related.

B.

Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage.

C.

Requires Ms. Giambi and her employer to each pay half of the cost of this coverage.

D.

Requires Ms. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.

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