AHIP AHM-250 - Healthcare Management: An Introduction
The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On
John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. Mr. Kerry visits his PCP, who sends him to have some blood tests. The PCP then refers Mr. Kerry to a specialist who hospitalizes him for on
The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inv
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i
Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves
The Fairway Health Group contracted with the Empire Corporation to provide behavioral healthcare services to Empire employees. As a condition of providing behavioral healthcare services, Fairway required Empire to contract with Fairway for basic medical s
Natalie Chan is a member of the Ultra Health Plan. Whenever she needs non-emergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Craig referred h
Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:
The cost of hospitalization for two days
Diagnostic tests performed in the hospital
Trans
The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be
One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the
