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Master the Network Management AHM-530 Exam with Confidence!

Questions 51

A health plan that delegates designated credentialing activities to an NCQA-centered or a Commission/URAC-centered credentials verification organization (CVO) is exempt from the due-diligence oversight requirements specified in the NCQA credentialing standards for all verification services for which the CVO has been certified:

Options:

A.

True

B.

False

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Questions 52

The Crimson Health Plan, a competitive medical plan (CMP), has entered into a Medicare risk contract. One true statement about Crimson is that, as a:

Options:

A.

CMP, Crimson is regulated by the federal government under the terms of the Tax Equity and Fiscal Responsibility Act (TEFRA)

B.

CMP, Crimson is not allowed to charge a Medicare enrollee a premium for any additional benefits it provides over and above Medicare benefits

C.

Provider under a Medicare risk contract, Crimson receives for its services a capitated payment equivalent to 85% of the AAPCC

D.

Provider under a Medicare risk contract, Crimson is required to deliver to members all Medicare-covered services, without regard to the cost of those services

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Questions 53

Assume that the national average cost per covered employee for PPO rental networks is $3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:

Options:

A.

$30,000

B.

$360,000

C.

$9,000,000

D.

$12,000,000

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Questions 54

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

Options:

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.

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Questions 55

The Omnibus Budget Reconciliation Act of 1986 (OBRA 1986) established the Programs of All-Inclusive Care for the Elderly (PACE). One characteristic of the PACE programs is that:

Options:

A.

They are available to United States citizens only after they reach age 65.

B.

They have an upper dollar limit.

C.

They receive a monthly capitation that is set at 100% of the Adjusted Average Per Capita Cost (AAPCC).

D.

PACE providers receive capitated payments only through the PACE agreement.

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Questions 56

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

Options:

A.

Telemedicine

B.

An electronic referral system

C.

Electronic data interchange

D.

Encounter reporting

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Questions 57

The provider contract that the Danube Health Plan has with the Viola Home Health Services Organization states that Danube will use a typical flat rate reimbursement arrangement to compensate Viola for the skilled nursing services it provides to Danube’s plan members. A portion of the contract’s reimbursement schedule is shown below:

Home Health Licensed Practical Nurse (LPN): $45 per visit or $90 per diem

Home Health Registered Nurse (RN): $50 per visit or $110 per diem

Last month, an LPN from Viola visited a Danube plan member and provided 1½ hours of home healthcare, and an RN from Viola visited another Danube plan member and provided 7 hours of home healthcare. The following statement(s) can correctly be made about Danube’s payment to Viola for these services:

Options:

A.

Danube most likely owes $90 for the LPN’s skilled nursing services and $110 for the RN’s skilled nursing services.

B.

Danube’s payment amount could be different from the amount called for in the reimbursement schedule if the level of care provided to one of these plan members was significantly different from the level of care normally provided by Viola’s RNs and LPNs.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

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Questions 58

The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

Options:

A.

Is a contract that creates a legally binding relationship between Enterprise and Teal

B.

Cannot include a confidentiality clause

C.

Serves as a delegation agreement between Enterprise and Teal

D.

Outlines the delegation oversight process

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Questions 59

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:

Options:

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

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Questions 60

Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgical procedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

Options:

A.

Upcoding

B.

A wrap-around

C.

Churning

D.

Unbundling

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Exam Code: AHM-530
Exam Name: Network Management
Last Update: Jun 14, 2024
Questions: 202

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