Free AHM-540 Exam Dumps Preview

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

Health plans often use accreditation as a means of evaluating the quality of care delivered to plan members. Accreditation of subacute care providers is available from the

Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.

The following statements are about accreditation. Select the answer choice containing the correct statement.

All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.

The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

7. One method that health plans use to address provider compliance with formularies is academic detailing.

Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans
typically use home healthcare include

1. The period prior to a hospital admission

2. The period following discharge from a hospital

In recent years, the demand for prescription drugs has increased dramatically. Factors that have contributed to this increase include

Drugs included in a health plan's formulary can be classified according to how freely they can be prescribed. By definition, a drug that requires some sort of review or approval by a plan physician or group

of physicians before the prescription can be filled is

The following statement(s) can correctly be made about accrediting agency standards for delegation:

1. The National Committee for Quality Assurance (NCQA) allows health plans to delegate all medical management functions, including the responsibility to perform delegation oversight activities

2. In some cases, accreditation standards for delegation oversight are reduced if the delegate has already been certified or accredited by the delegator's accrediting agency

Designing effective medical management programs for Medicare beneficiaries requires an understanding of the unique health needs of the Medicare population. One characteristic of Medicare beneficiaries is that they typically

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

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

The following statements are about medical management considerations for dental care. Select the answer choice containing the correct statement.

Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types ofperformance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

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

Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the

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

Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):

1. FEHBP plan members who have exhausted the health plan's usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM)

2. All health plans that cover federal employees are required to develop and implement patient safety initiatives

When conducting performance assessment, a health pln may classify the key processes associated with its services into the following categories: high-risk, high-volume, problem-prone, and high-cost.

The following statements are about this classification of processes. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

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

Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.