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Get Certified: Proven Methods to Pass the AHIP AHM-530 Exam

Questions 11

The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

Options:

A.

delegator, and Aegean is ultimately responsible for Brandon’s performance

B.

delegator, and Silhouette is ultimately responsible for Brandon’s performance

C.

subdelegate, and Aegean is ultimately responsible for Brandon’s performance

D.

subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

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Questions 12

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:

The Apex Company, a managed vision care organization (MVCO)

The Baxter Managed Behavioral Healthcare Organization (MBHO)

The Cheshire Dental Health Maintenance Organization (DHMO)

As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA’s accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

Options:

A.

Apex and Baxter only

B.

Apex and Cheshire only

C.

Baxter and Cheshire only

D.

Baxter only

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Questions 13

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

Options:

A.

Require a medical examination prior to accepting an application for employment

B.

Include in the employment application questions pertaining to health status

C.

Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges

D.

Require applicants to answer questions pertaining to the use of drugs and alcohol

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Questions 14

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.

One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.

Options:

A.

authorization

B.

provider relations

C.

credentialing

D.

utilization management

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Questions 15

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.

Options:

A.

True

B.

False

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Questions 16

Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as

Options:

A.

An academic practitioner

B.

An independent practitioner

C.

Anetwork manager

D.

Ahospital-based specialist

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Questions 17

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

Options:

A.

Hold plan members responsible for unreimbursed charges or unpaid claims

B.

Allow providers to develop their own standards of care

C.

Adhere to specified disclosure requirements related to provider contract termination

D.

File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

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Questions 18

The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Walton’s MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for

Options:

A.

8 cents per tablet, but the pharmacy can bill the subscriber for the remaining 2 cents per tablet

B.

8 cents per tablet, and the pharmacy cannot bill the subscriber for the remaining 2 cents per tablet

C.

10 cents per tablet, but the pharmacy must refund the extra 2 cents per tablet to the subscriber

D.

10 cents per tablet, and the pharmacy is not required to refund the extra 2 cents per tablet to the subscriber

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Questions 19

Provider panels can be either narrow or broad. Compared to a similarly sized health plan that uses a broad provider panel, a health plan that uses a narrow provider panel most likely can expect to

Options:

A.

Experience higher contracting costs

B.

Encounter increased difficulty in utilization management

C.

Have to charge higher health plan premiums

D.

Experience lower provider relations costs

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Questions 20

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

Options:

A.

Dr. Kwan most likely was required to seek authorization from Poplar before performing this particular service.

B.

Dr. Kwan most likely was paid on a FFS basis for providing this service.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

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Exam Code: AHM-530
Exam Name: Network Management
Last Update: Jul 25, 2024
Questions: 202

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