AHM 530 EXAM Questions AND Correct Answers
A contract provision that commits a provider to follow the rules and
procedures contained in a provider manual - ✔✔compliance with
administrative and operational policies
A contract provision that limits benefits to a specific number of visits,
treatments, or supplies during each benefit year - ✔✔benefits with
special limitations
a health plan enters into a professional services capitation
arrangement whenever the health plan
a. contracts with a medical group, clinic, or multi-specialty IPA that
assumes responsibility for the costs of all physician services related to
a patient's care
b. pays individual specialists to provide only radiology services to all
plan members
c. transfers all financial risk for healthcare services to a provider
organization and the provider, in turn, covers virtually all a patient's
medical expenses
d. contracts with a primary care provider to cover primary care
services - ✔✔a. contracts with a medical group, clinic, or multi-
specialty IPA that assumes responsibility for the costs of all physician
services related to a patient's care
,A health plan has several options for delivering pharmacy services to
its members. Each option has potential advantages to a health plan.
An advantage to a health plan of using:
a. performance-based open networks tend to increase participation in
the pharmacy network
b. closed networks improve the health plan's ability to set standards
and implement cost-control
programs for pharmacy services
c. Customized networks typically are inexpensive to operate
d. open networks tend to improve the health plan's ability to control
pharmaceutical costs - ✔✔b. closed networks improve the health
plan's ability to set standards and implement cost-control
programs for pharmacy services
A health plan is developing a network, and it is believed that the most
important consideration of potential members is accessibility. The
plan will likely
a. focus on provider selection criteria
b. create a large, very inclusive primary care panel
c. create a large, very inclusive specialist panel
d. establish a narrow network - ✔✔b. create a large, very inclusive
primary care panel
,A health plan is thinking about contracting with a new provider. In
which of the following way(s) can the health plan obtain information
about the provider?
I. the health plan can examine the provider application
II. the health plan can can override HIPAA privacy interest to review
the new provider's patient records
III. the health plan can check with current purchases for information
about network candidates
IV. the health plan can check with accrediting agencies
a. I and II
b. I, II, and III
c. I, III, and IV
I, II, III and IV - ✔✔c. I, III, and IV
A health plan may choose to delegate a function like provider
credentialing because:
a. the health plan's staff seeks external expertise for the delegated
activity
b. the health plan does not want to dedicate internal resources to
perform the delegated activity
, c. the health plan realizes its current information system cannot
handle the demands of a function
d. all of the above - ✔✔d. all of the above
A health plan that wishes to improve the performance of its network
management staff should consider which of the following types of
support and training?
I. Education about internal operations
II. Information systems support
III. Cross-training in facilities maintenance
IV. Forums for sharing information both within the department and
within the health plan
a. I and II
b. II and III
c. I, II, and IV
d. II, III, and IV - ✔✔c. I, II, and IV
a health plan's contract negotiation team consists of several skilled
individuals from different areas. At least one of the members is
responsible for evaluation the wording of specific clauses to ensure
that the health plan's rights are protected, as well as to ensure that
A contract provision that commits a provider to follow the rules and
procedures contained in a provider manual - ✔✔compliance with
administrative and operational policies
A contract provision that limits benefits to a specific number of visits,
treatments, or supplies during each benefit year - ✔✔benefits with
special limitations
a health plan enters into a professional services capitation
arrangement whenever the health plan
a. contracts with a medical group, clinic, or multi-specialty IPA that
assumes responsibility for the costs of all physician services related to
a patient's care
b. pays individual specialists to provide only radiology services to all
plan members
c. transfers all financial risk for healthcare services to a provider
organization and the provider, in turn, covers virtually all a patient's
medical expenses
d. contracts with a primary care provider to cover primary care
services - ✔✔a. contracts with a medical group, clinic, or multi-
specialty IPA that assumes responsibility for the costs of all physician
services related to a patient's care
,A health plan has several options for delivering pharmacy services to
its members. Each option has potential advantages to a health plan.
An advantage to a health plan of using:
a. performance-based open networks tend to increase participation in
the pharmacy network
b. closed networks improve the health plan's ability to set standards
and implement cost-control
programs for pharmacy services
c. Customized networks typically are inexpensive to operate
d. open networks tend to improve the health plan's ability to control
pharmaceutical costs - ✔✔b. closed networks improve the health
plan's ability to set standards and implement cost-control
programs for pharmacy services
A health plan is developing a network, and it is believed that the most
important consideration of potential members is accessibility. The
plan will likely
a. focus on provider selection criteria
b. create a large, very inclusive primary care panel
c. create a large, very inclusive specialist panel
d. establish a narrow network - ✔✔b. create a large, very inclusive
primary care panel
,A health plan is thinking about contracting with a new provider. In
which of the following way(s) can the health plan obtain information
about the provider?
I. the health plan can examine the provider application
II. the health plan can can override HIPAA privacy interest to review
the new provider's patient records
III. the health plan can check with current purchases for information
about network candidates
IV. the health plan can check with accrediting agencies
a. I and II
b. I, II, and III
c. I, III, and IV
I, II, III and IV - ✔✔c. I, III, and IV
A health plan may choose to delegate a function like provider
credentialing because:
a. the health plan's staff seeks external expertise for the delegated
activity
b. the health plan does not want to dedicate internal resources to
perform the delegated activity
, c. the health plan realizes its current information system cannot
handle the demands of a function
d. all of the above - ✔✔d. all of the above
A health plan that wishes to improve the performance of its network
management staff should consider which of the following types of
support and training?
I. Education about internal operations
II. Information systems support
III. Cross-training in facilities maintenance
IV. Forums for sharing information both within the department and
within the health plan
a. I and II
b. II and III
c. I, II, and IV
d. II, III, and IV - ✔✔c. I, II, and IV
a health plan's contract negotiation team consists of several skilled
individuals from different areas. At least one of the members is
responsible for evaluation the wording of specific clauses to ensure
that the health plan's rights are protected, as well as to ensure that
