AHIP AHM-540 - Medical Management

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say

Health plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say

1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days

2. That the timeframe is accelerated for expedited appeals

3. That the review period begins when the appeal arrives at a health plan

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select the term or phrase in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms or phrases you have chosen.

TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.

If Ms. Stanley agrees to the generic substitution, she will receive a drug that

Determine whether the following statement is true or false:

With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs.

Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which

1. A significant percentage of those treated with the initial therapy will require the second therapy

2. The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects

The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

Administrative costs for case management ..........$40,000

Actual medical care expenses for patients under case management ..........$680,000

Projected medical care expenses for the same patients without case management ..........$900,000

This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on