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AHIP AHM-250 - Healthcare Management: An Introduction

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Total 367 questions

In claims administration terminology, a claims investigation is correctly defined as the process of

A.

reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patterns

B.

obtaining all the information necessary to determine the appropriate amount to pay on a given claim

C.

routinely reviewing and processing a claim for either payment or denial

D.

assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatment

As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:

    Brad Van Note, age 28, is taking many different, costly medications for

A.

Mr. Van Note, Mr. Albrecht, and Ms. Cromartie

B.

Mr. Van Note and Ms. Cromartie only

C.

Mr. Van Note and Mr. Albrecht only

D.

Mr. Albrecht and Ms. Cromartie only

In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:

A.

The GLB Act allows convergence among the transaction

B.

A only

C.

Both A and B

D.

B only

E.

Neither A nor B

Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic dr

A.

CCC, AAA, BBB

B.

BBB, CCC, AAA

C.

BBB, AAA, CCC

D.

CCC, BBB, AAA

A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.

A.

Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.

B.

Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.

C.

In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.

D.

The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare health

A.

quality standards

B.

accreditation decisions

C.

standards of care

D.

performance measures

Identify the CORRECT statement(s):

(A) Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.

(B) Gender of the group's participants has no effect on the likelihood of loss.

A.

All of the listed options

B.

B & C

C.

None of the listed options

D.

A & C

A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must

A.

$525

B.

$1,050

C.

$2,100

D.

$5,250

In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of

A.

Prospective review

B.

Concurrent review

C.

D.

A, B, and C

E.

A and B only

F.

A and C only

G.

B only

Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:

A.

State that Dr. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.

B.

Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract.

C.

Give Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.

D.

Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives Dr. Aldridge at least 90-days' notice of its intent to terminate the contract.