TEXAS DELIVERY SYSTEMS MANAGEMENT EXAM COMPLETE PRACTICE TEST BANK
QUESTIONS AND ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027
CERTIFICATION PREP & COMPREHENSIVE STUDY GUIDE
Examiner/Administrator: Texas Department of Insurance
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TEXAS DELIVERY SYSTEMS MANAGEMENT EXAM
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
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TEXAS DEPARTMENT OF INSURANCE || ALIGNED WITH CURRENT DELIVERY SYSTEMS
MANAGEMENT REGULATORY BLUEPRINTS || HEALTHCARE OPERATIONS COMPLIANCE
|| UTILIZATION MANAGEMENT PRINCIPLES || NETWORK ADMINISTRATION ||
PROVIDER CONTRACTING STANDARDS || QUALITY IMPROVEMENT SYSTEMS || 100%
VERIFIED ACADEMIC REVIEW MATERIAL || PROFESSIONAL CERTIFICATION
PREPARATION || UPDATED HEALTHCARE REGULATORY STUDY GUIDE || PROFESSIONAL
EXAMINATION USE ONLY
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Questions 1–10 → Texas Healthcare Delivery Systems & Regulatory
Compliance
,Q1. A managed care organization operating in Texas plans to implement a new
provider reimbursement methodology that shifts from fee-for-service payments to a
value-based arrangement tied to patient outcomes. Before implementation, the
compliance director must evaluate the primary regulatory concern associated with the
change. Which consideration is MOST critical?
A. Whether the payment model increases provider marketing expenditures
B. Whether the reimbursement structure complies with state and federal fraud and
abuse regulations
C. Whether providers prefer capitated arrangements over bundled payments
D. Whether the organization can eliminate utilization review procedures entirely
Correct Answer: 🔴 B. Whether the reimbursement structure complies with state
and federal fraud and abuse regulations
Explanation: 🔹 Value-based reimbursement arrangements may create regulatory
exposure involving anti-kickback statutes, Stark Law implications, and state
healthcare fraud provisions. The organization must ensure compensation models are
tied to legitimate quality metrics and not improper referral incentives. Option A is
secondary and unrelated to the core legal risk. Option C addresses provider
preference rather than compliance. Option D is incorrect because utilization review
remains necessary under most delivery systems.
Q2. A Texas health maintenance organization (HMO) receives multiple complaints that
enrollees are unable to obtain specialist referrals within mandated timeframes. Which
operational failure is MOST likely contributing to the issue?
A. Excessive network adequacy and access limitations
B. Overutilization of electronic health records
C. Expansion of preventive wellness programs
D. Increased member satisfaction survey participation
Correct Answer: 🔴 A. Excessive network adequacy and access limitations
Explanation: 🔹 Texas HMOs must maintain sufficient provider networks to ensure
timely access to care. Delayed specialist access commonly indicates inadequate
network capacity, geographic shortages, or insufficient referral coordination.
,Electronic health records generally improve coordination rather than hinder it.
Preventive programs and survey participation are unrelated to specialist access
delays.
Q3. A delivery systems manager is reviewing delegated credentialing activities
performed by a contracted physician group. Which responsibility ultimately remains
with the health plan despite delegation?
A. Determining physician office furniture standards
B. Monitoring and oversight of delegated credentialing performance
C. Selecting physician continuing education topics
D. Conducting annual provider tax audits
Correct Answer: 🔴 B. Monitoring and oversight of delegated credentialing
performance
Explanation: 🔹 Even when credentialing activities are delegated, the health plan
retains accountability for ensuring delegated entities comply with accreditation and
regulatory standards. Oversight audits, performance monitoring, and corrective
action requirements remain essential. Furniture standards and tax audits are
unrelated to credentialing oversight, while continuing education selection is not the
plan’s primary delegated responsibility.
Q4. A utilization management nurse denies inpatient admission based on insufficient
clinical documentation. Under Texas healthcare regulations and standard utilization
management principles, what action should occur next?
A. Automatic cancellation of the patient’s insurance coverage
B. Immediate referral of the patient to law enforcement
C. Notification of appeal rights and review procedures to the provider and member
D. Permanent exclusion of the admitting physician from the provider network
Correct Answer: 🔴 C. Notification of appeal rights and review procedures to the
provider and member
, Explanation: 🔹 Utilization management decisions involving adverse determinations
require transparent appeal procedures and timely notification rights. Due process
protections are fundamental in managed care regulation. Insurance cancellation and
law enforcement referrals are inappropriate absent fraud. Provider exclusion would
require separate disciplinary procedures and evidence.
Q5. A healthcare administrator seeks to improve continuity of care across multiple
provider groups participating in an integrated delivery network (IDN). Which strategy
would BEST support this objective?
A. Restricting all patient data sharing between providers
B. Implementing interoperable care coordination systems
C. Eliminating case management services
D. Limiting primary care provider involvement in specialty referrals
Correct Answer: 🔴 B. Implementing interoperable care coordination systems
Explanation: 🔹 Integrated delivery networks rely heavily on interoperable systems to
coordinate treatment, reduce fragmentation, and improve transitions of care. Shared
clinical information supports continuity and patient safety. Restricting data sharing
worsens fragmentation. Eliminating case management reduces coordination
effectiveness. Limiting PCP involvement undermines coordinated referral
management.
Q6. A managed care compliance officer discovers that a delegated vendor failed to
meet turnaround requirements for prior authorization requests. What is the MOST
appropriate corrective action?
A. Ignore the issue if no patient harm occurred
B. Require corrective action planning and enhanced oversight monitoring
C. Terminate all provider contracts immediately
D. Transfer all utilization review decisions to patients
Correct Answer: 🔴 B. Require corrective action planning and enhanced oversight
monitoring
QUESTIONS AND ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027
CERTIFICATION PREP & COMPREHENSIVE STUDY GUIDE
Examiner/Administrator: Texas Department of Insurance
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
TEXAS DELIVERY SYSTEMS MANAGEMENT EXAM
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
TEXAS DEPARTMENT OF INSURANCE || ALIGNED WITH CURRENT DELIVERY SYSTEMS
MANAGEMENT REGULATORY BLUEPRINTS || HEALTHCARE OPERATIONS COMPLIANCE
|| UTILIZATION MANAGEMENT PRINCIPLES || NETWORK ADMINISTRATION ||
PROVIDER CONTRACTING STANDARDS || QUALITY IMPROVEMENT SYSTEMS || 100%
VERIFIED ACADEMIC REVIEW MATERIAL || PROFESSIONAL CERTIFICATION
PREPARATION || UPDATED HEALTHCARE REGULATORY STUDY GUIDE || PROFESSIONAL
EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Questions 1–10 → Texas Healthcare Delivery Systems & Regulatory
Compliance
,Q1. A managed care organization operating in Texas plans to implement a new
provider reimbursement methodology that shifts from fee-for-service payments to a
value-based arrangement tied to patient outcomes. Before implementation, the
compliance director must evaluate the primary regulatory concern associated with the
change. Which consideration is MOST critical?
A. Whether the payment model increases provider marketing expenditures
B. Whether the reimbursement structure complies with state and federal fraud and
abuse regulations
C. Whether providers prefer capitated arrangements over bundled payments
D. Whether the organization can eliminate utilization review procedures entirely
Correct Answer: 🔴 B. Whether the reimbursement structure complies with state
and federal fraud and abuse regulations
Explanation: 🔹 Value-based reimbursement arrangements may create regulatory
exposure involving anti-kickback statutes, Stark Law implications, and state
healthcare fraud provisions. The organization must ensure compensation models are
tied to legitimate quality metrics and not improper referral incentives. Option A is
secondary and unrelated to the core legal risk. Option C addresses provider
preference rather than compliance. Option D is incorrect because utilization review
remains necessary under most delivery systems.
Q2. A Texas health maintenance organization (HMO) receives multiple complaints that
enrollees are unable to obtain specialist referrals within mandated timeframes. Which
operational failure is MOST likely contributing to the issue?
A. Excessive network adequacy and access limitations
B. Overutilization of electronic health records
C. Expansion of preventive wellness programs
D. Increased member satisfaction survey participation
Correct Answer: 🔴 A. Excessive network adequacy and access limitations
Explanation: 🔹 Texas HMOs must maintain sufficient provider networks to ensure
timely access to care. Delayed specialist access commonly indicates inadequate
network capacity, geographic shortages, or insufficient referral coordination.
,Electronic health records generally improve coordination rather than hinder it.
Preventive programs and survey participation are unrelated to specialist access
delays.
Q3. A delivery systems manager is reviewing delegated credentialing activities
performed by a contracted physician group. Which responsibility ultimately remains
with the health plan despite delegation?
A. Determining physician office furniture standards
B. Monitoring and oversight of delegated credentialing performance
C. Selecting physician continuing education topics
D. Conducting annual provider tax audits
Correct Answer: 🔴 B. Monitoring and oversight of delegated credentialing
performance
Explanation: 🔹 Even when credentialing activities are delegated, the health plan
retains accountability for ensuring delegated entities comply with accreditation and
regulatory standards. Oversight audits, performance monitoring, and corrective
action requirements remain essential. Furniture standards and tax audits are
unrelated to credentialing oversight, while continuing education selection is not the
plan’s primary delegated responsibility.
Q4. A utilization management nurse denies inpatient admission based on insufficient
clinical documentation. Under Texas healthcare regulations and standard utilization
management principles, what action should occur next?
A. Automatic cancellation of the patient’s insurance coverage
B. Immediate referral of the patient to law enforcement
C. Notification of appeal rights and review procedures to the provider and member
D. Permanent exclusion of the admitting physician from the provider network
Correct Answer: 🔴 C. Notification of appeal rights and review procedures to the
provider and member
, Explanation: 🔹 Utilization management decisions involving adverse determinations
require transparent appeal procedures and timely notification rights. Due process
protections are fundamental in managed care regulation. Insurance cancellation and
law enforcement referrals are inappropriate absent fraud. Provider exclusion would
require separate disciplinary procedures and evidence.
Q5. A healthcare administrator seeks to improve continuity of care across multiple
provider groups participating in an integrated delivery network (IDN). Which strategy
would BEST support this objective?
A. Restricting all patient data sharing between providers
B. Implementing interoperable care coordination systems
C. Eliminating case management services
D. Limiting primary care provider involvement in specialty referrals
Correct Answer: 🔴 B. Implementing interoperable care coordination systems
Explanation: 🔹 Integrated delivery networks rely heavily on interoperable systems to
coordinate treatment, reduce fragmentation, and improve transitions of care. Shared
clinical information supports continuity and patient safety. Restricting data sharing
worsens fragmentation. Eliminating case management reduces coordination
effectiveness. Limiting PCP involvement undermines coordinated referral
management.
Q6. A managed care compliance officer discovers that a delegated vendor failed to
meet turnaround requirements for prior authorization requests. What is the MOST
appropriate corrective action?
A. Ignore the issue if no patient harm occurred
B. Require corrective action planning and enhanced oversight monitoring
C. Terminate all provider contracts immediately
D. Transfer all utilization review decisions to patients
Correct Answer: 🔴 B. Require corrective action planning and enhanced oversight
monitoring
