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

Questions 21

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

Options:

A.

Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates Dr. Quill’s contract without cause

B.

Requires that Regal must base its decision to terminate Dr. Quill’s contract on clinical criteria only

C.

Allows either Regal or Dr. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process

D.

Allows Regal to terminate Dr. 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

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Questions 22

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

Options:

A.

Subrogation

B.

Partial capitation

C.

Coordination of benefits

D.

Aremedy provision

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Questions 23

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.

Options:

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 Dr. Zorn advance notice of its intent to amend the contract.

D.

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.

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Questions 24

A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

Options:

A.

provisions for marketing the plan’s product

B.

payment arrangements between the plan and the provider

C.

verification of the plan’s eligibility to do business

D.

management of the contents of members’ medical records

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Questions 25

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

Options:

A.

has a legal right to access a prospective provider’s confidential medical records at any time

B.

must limit any evaluations of a prospective provider’s office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day

C.

is prohibited by law from conducting primary verification of such data as a prospective provider’s scope of medical malpractice insurance coverage and federal tax identification number

D.

must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

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Questions 26

The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

Options:

A.

A disadvantage of using open pharmacy networks is that the health plan’s control over costs is limited to setting reimbursement levels.

B.

An advantage of using performance-based systems is that they tend to increase participation in the health plan’s pharmacy network.

C.

A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.

D.

All of these statements are correct.

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Questions 27

Health plans use a variety of sources to find candidates to recruit for their provider networks. In general, two of the most effective methods of finding candidates are through

Options:

A.

Word of mouth and on-site training programs

B.

Word of mouth and direct mail

C.

Advertisements in local newspapers and on-site training programs

D.

Advertisements in local newspapers and direct mail

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Questions 28

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

Options:

A.

Specialty IPA

B.

Disease management company

C.

Single specialty management specialist

D.

Specialty network management company

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Questions 29

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

Options:

A.

True

B.

False

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Questions 30

The Ionic Group, a provider group with 10,000 plan members, purchased for its hospital risk pool aggregate stop-loss insurance with a threshold of 110% of projected costs and a 10% coinsurance provision. Ionic funds the hospital risk pool at $40 per member per month (PMPM).

If Ionic’s actual hospital costs are $5,580,000 for the year, then, under the aggregate stop-loss agreement, the stop-loss insurer is responsible for reimbursing Ionic in the amount of

Options:

A.

$30,000

B.

$270,000

C.

$300,000

D.

$702,000

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Exam Code: AHM-530
Exam Name: Network Management
Last Update: Jun 24, 2024
Questions: 202

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