AHM-530 Sample Questions & Answers

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.One important activity within the scope of network management is ensuring the quality of the health plan's provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan's pre-established criteria for participation in the network. A.authorizationB.provider relationsC.credentialingD.utilization management

One important aspect of network management is profiling, or provider profiling. Profiling is most often used to: A.measure the overall performance of providers who are already participants in the networkB.assess a provider's overall satisfaction with a plan's service protocols and other operational areasC.verify a prospective provider's professional licenses, certifications, and trainingD.familiarize a provider with a plan's procedures for authorizations and referrals

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: A.determine the number of healthcare services delivered to plan membersB.monitor the types of services provided by the health plan's entire provider networkC.evaluate providers' practice patterns and compliance with the health plan's procedures for the delivery of careD.all of the above

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon's employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as: A.a carrier guarantee arrangementB.open accessC.total replacement coverageD.selective contract coverage

Federal laws--including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Act-- have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate:Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest.From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based. A.Regulation 1 - The Ethics in Patient Referrals ActRegulation 2 - The HMO Act of 1973B.Regulation 1 - The HMO Act of 1973Regulation 2 - The Ethics in Patient Referrals ActC.Regulation 1 - ERISA -Regulation 2 - The Federal Trade Commission ActD.Regulation 1 - The Federal Trade Commission ActRegulation 2 - ERISA