AHM 530 QUESTIONS AND VERIFIED ANSWERS
True or False?
Network management includes all activities conducted by a health plan to design,
assemble, monitor, and maintain a network of providers - Answers - True
Which of the following statements about the history and development of network
management is/are correct?
I. Network management is a recent movement with the healthcare community beginning
with the passage of the Affordable Care Act (ACA) in 2010.
II. Network management began with the introduction of managed care when health
maintenance organizations (HMOs) required patients to select a PCP to coordinate their
care with other providers
III. The introduction of preferred provider networks reinforced the movement toward
strict network management
IV. Network management has assumed increased importance as new models of care
delivery such as patient-centered medical homes (PCMHs) have become increasingly
common
a. I and II
b. II and III
c. II and IV
d. I, II, III, and IV - Answers - c. II and IV
True or False?
A health provider network typically includes only PCP's and hospitals - Answers - False
Typical network management activities include which, if any, of the following?
I. Identifying and recruiting potential network providers.
II. Providing ongoing education, support, and service for providers and their staff
III. Negotiating contract language and reimbursement
IV. Terminating providers
a. I
b. I and II
c. I, II, and III
d. I, II, III, and IV - Answers - d. I, II, III, and IV
Which of the following statements is/are correct about credentialing?
,I. Credentialing is a review process conducted by or for a health plan to determine the
current clinical competence of a provider
II. Credentialing must be conducted directly by a health plan
III. Credentialing is typically done only at the initial recruitment of a provider
IV. During the credentialing process, the provider's licenses, certifications, training and
other qualifications are obtained and verified
a. I
b. II and III
c. I and IV
d. II and IV - Answers - c. I and IV
Many health plans have three basic categories of network management personnel.
Which of the following is/are part of these categories?
I. Network management director
II. Contracting specialists
III. Case managers
IV. Provider relations representatives
a. I
b. II and III
c. II and IV
d. I, II, and IV - Answers - d. I, II, and IV
Friendly Health (Friendly) is a health plan operating in a less mature market. Adam
works as the medical director at Friendly. Beth works as the pharmacy director at
Friendly. Charles is a non-clinician officer, who heads the actuarial department at
Friendly. Darlene is an attorney and a non-clinician officer. She heads an area
responsible for contracting and provider service. Which statement best describes the
likely nature of a network management supervision at Friendly?
a. Adam, as the medical director of a plan in a less more market, is likely to have the
ultimate authority over all network management activities
b. Beth, as the pharmacy director of a plan in a time of rising drug costs, is likely to
share network management supervision responsibilities with medical director Adam.
c. Charles, as a non-clinician officer and actuary, is likely to have ultimate authority over
all network management activities in - Answers - a. Adam, as the medical director of a
plan in a less more market, is likely to have the ultimate authority over all network
management activities
True or False?
The committee overseeing network management typically reports directly to the health
plan's board of directors - Answers - True
,Contracting personnel must coordinate their activities with which, if any, of the following
health plan departments?
I. Claims department
II. Information systems department
III. Marketing department
IV. Facilities department
a. I
b. I and II
c. I, II, and III
d. I, II, III, and IV - Answers - c. I, II, and III
Provider relations representatives are typically responsible for which, if any, of the
following?
I. Assisting provider with clinical decisions
II. Recruiting and assisting with the selection of new providers
III. Educating providers about health plan developments
IV. Negotiating and executing contracts with providers
a. I and II
b. II and III
c. I, II, and IV
d. II, III, and IV - Answers - b. II and III
True or False?
Network management field staff are also referred to as provider relations
representatives - Answers - True
Which of the following statement is/are correct about profiling?
I. Some health plans use profiling information to select network providers whose
practice patterns appear to be compatible with network goals and policies.
II. Sources of profiling information include a helath plan's records of claims, data
gathered by health plan purchasers, and reports from providers applying for the health
plan's network
III. Profiling can be used to measure the overall performance of providers in a health
plan's network
IV. Provider profiling is considered an illegal practice in many states
a. I
b. IV
c. I and II
d. I, II, and II only - Answers - d. I, II, and II only
, True or False?
Some plan delegate credentialing information collection and verification to credentials
verification organizations (CVOs) to set up a "checks and balances" system for the
network - Answers - True
True or False?
Some plans find it more efficient for contracting specialists to perform credentialing and
periodic recredentialing because of their knowledge of and proximity to area providers. -
Answers - False
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 - Answers - c. I, II, and IV
The following activiites are the responsibility of either the Nova Health Plan's risk
management department or its medical management department:
I. Protecting Nova's members against harm from medical care
II. Improving the overall health status of Nova members by coordinating care across
individual episodes of care and the different providers who treat the member
III. Protecting Nova against financial loss associated with the delivery of healthcare
IV. Establishing outreach programs to encourage the use of preventive health services
by Nova's members
a. I, II, and III
b. I, III, and IV
c. I and III
d. II and IV - Answers - c. I and III
Network managers rely on a health plan's claims administration department for much of
the information needed to manage the performance of providers who are not under a
capitation arrangement. Examining claims submitted to a health plan's claims
administration department enables the health plan to:
True or False?
Network management includes all activities conducted by a health plan to design,
assemble, monitor, and maintain a network of providers - Answers - True
Which of the following statements about the history and development of network
management is/are correct?
I. Network management is a recent movement with the healthcare community beginning
with the passage of the Affordable Care Act (ACA) in 2010.
II. Network management began with the introduction of managed care when health
maintenance organizations (HMOs) required patients to select a PCP to coordinate their
care with other providers
III. The introduction of preferred provider networks reinforced the movement toward
strict network management
IV. Network management has assumed increased importance as new models of care
delivery such as patient-centered medical homes (PCMHs) have become increasingly
common
a. I and II
b. II and III
c. II and IV
d. I, II, III, and IV - Answers - c. II and IV
True or False?
A health provider network typically includes only PCP's and hospitals - Answers - False
Typical network management activities include which, if any, of the following?
I. Identifying and recruiting potential network providers.
II. Providing ongoing education, support, and service for providers and their staff
III. Negotiating contract language and reimbursement
IV. Terminating providers
a. I
b. I and II
c. I, II, and III
d. I, II, III, and IV - Answers - d. I, II, III, and IV
Which of the following statements is/are correct about credentialing?
,I. Credentialing is a review process conducted by or for a health plan to determine the
current clinical competence of a provider
II. Credentialing must be conducted directly by a health plan
III. Credentialing is typically done only at the initial recruitment of a provider
IV. During the credentialing process, the provider's licenses, certifications, training and
other qualifications are obtained and verified
a. I
b. II and III
c. I and IV
d. II and IV - Answers - c. I and IV
Many health plans have three basic categories of network management personnel.
Which of the following is/are part of these categories?
I. Network management director
II. Contracting specialists
III. Case managers
IV. Provider relations representatives
a. I
b. II and III
c. II and IV
d. I, II, and IV - Answers - d. I, II, and IV
Friendly Health (Friendly) is a health plan operating in a less mature market. Adam
works as the medical director at Friendly. Beth works as the pharmacy director at
Friendly. Charles is a non-clinician officer, who heads the actuarial department at
Friendly. Darlene is an attorney and a non-clinician officer. She heads an area
responsible for contracting and provider service. Which statement best describes the
likely nature of a network management supervision at Friendly?
a. Adam, as the medical director of a plan in a less more market, is likely to have the
ultimate authority over all network management activities
b. Beth, as the pharmacy director of a plan in a time of rising drug costs, is likely to
share network management supervision responsibilities with medical director Adam.
c. Charles, as a non-clinician officer and actuary, is likely to have ultimate authority over
all network management activities in - Answers - a. Adam, as the medical director of a
plan in a less more market, is likely to have the ultimate authority over all network
management activities
True or False?
The committee overseeing network management typically reports directly to the health
plan's board of directors - Answers - True
,Contracting personnel must coordinate their activities with which, if any, of the following
health plan departments?
I. Claims department
II. Information systems department
III. Marketing department
IV. Facilities department
a. I
b. I and II
c. I, II, and III
d. I, II, III, and IV - Answers - c. I, II, and III
Provider relations representatives are typically responsible for which, if any, of the
following?
I. Assisting provider with clinical decisions
II. Recruiting and assisting with the selection of new providers
III. Educating providers about health plan developments
IV. Negotiating and executing contracts with providers
a. I and II
b. II and III
c. I, II, and IV
d. II, III, and IV - Answers - b. II and III
True or False?
Network management field staff are also referred to as provider relations
representatives - Answers - True
Which of the following statement is/are correct about profiling?
I. Some health plans use profiling information to select network providers whose
practice patterns appear to be compatible with network goals and policies.
II. Sources of profiling information include a helath plan's records of claims, data
gathered by health plan purchasers, and reports from providers applying for the health
plan's network
III. Profiling can be used to measure the overall performance of providers in a health
plan's network
IV. Provider profiling is considered an illegal practice in many states
a. I
b. IV
c. I and II
d. I, II, and II only - Answers - d. I, II, and II only
, True or False?
Some plan delegate credentialing information collection and verification to credentials
verification organizations (CVOs) to set up a "checks and balances" system for the
network - Answers - True
True or False?
Some plans find it more efficient for contracting specialists to perform credentialing and
periodic recredentialing because of their knowledge of and proximity to area providers. -
Answers - False
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 - Answers - c. I, II, and IV
The following activiites are the responsibility of either the Nova Health Plan's risk
management department or its medical management department:
I. Protecting Nova's members against harm from medical care
II. Improving the overall health status of Nova members by coordinating care across
individual episodes of care and the different providers who treat the member
III. Protecting Nova against financial loss associated with the delivery of healthcare
IV. Establishing outreach programs to encourage the use of preventive health services
by Nova's members
a. I, II, and III
b. I, III, and IV
c. I and III
d. II and IV - Answers - c. I and III
Network managers rely on a health plan's claims administration department for much of
the information needed to manage the performance of providers who are not under a
capitation arrangement. Examining claims submitted to a health plan's claims
administration department enables the health plan to:
