AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 171:

  One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. A formulary is defined as

  A. a listing of drugs classified by therapeutic category or disease class that are considered preferred therapy for a given managed population and that are to be used by a health plan's providers in prescribing medications

  B. a reduction in the price of a particular pharmaceutical obtained by the PBM from the pharmaceutical manufacturer

  C. drugs ordered and delivered through the mail to the PBM's plan members at a reduced cost

  D. an identification card issued by the PBM to its plan members

  Correct Answer: A

• Question 172:

  One characteristic of the accreditation process for MCOs is that

  A. an accrediting agency typically conducts an on-site review of an MCO's operations, but it does not review an MCO's medical records or assess its member service systems

  B. each accrediting organization has its own standards of accreditation

  C. the accrediting process is mandatory for all MCOs

  D. government agencies conduct all accreditation activities for MCOs

  Correct Answer: B

• Question 173:

  The Advantage Health Plan recently added the following features to its member services program:

  1.

  IVR

  2.

  Active member outreach program

  3.

  Advantage's member services staffing needs are likely to increase as a result of

  A. 1

  B. 2

  C. 1 and 2

  D. Neither 1 nor 2

  Correct Answer: B

• Question 174:

  The Clover Group is a for-profit MCO that operates in the United States. The Valentine Group owns all of Clover's stock. The Valentine Group's sole business is the ownership of controlling interests in the shares of other companies. This information indic

  A. holding company of the Valentine Group

  B. sister corporation of the Valentine Group

  C. parent company of the Valentine Group

  D. subsidiary of the Valentine Group

  Correct Answer: D

• Question 175:

  The Citywide Health Group is a large provider-based health plan that includes physician groups, hospitals, and other facilities. In order to oversee and manage the operation of the organization, Citywide has established an enterprise scheduling system. The

  A. provide information to Citywide's management regarding provider licensure, certification, and malpractice history

  B. detect instances of overutilization, underutilization, or inappropriate utilization of medical resources

  C. allow Citywide's different components to function as a single organization in arranging access to facilities and resources

  D. facilitate the processing of requests for authorization of payment of benefits

  Correct Answer: C

• Question 176:

  Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays a

  A. fixed amount in advance for each medical service the member receives

  B. a small fee such as $10 or $15 that a member pays at the time of an office visit to a network provider

  C. a fixed, monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need, no matter how often the member uses medical services

  D. specified amount of the member's medical expenses before any benefits are paid by the HMO

  Correct Answer: C

• Question 177:

  One distinction that can be made between a staff model HMO and a group model HMO is that, in a staff model HMO, participating physicians are Back to Top

  A. Employees of the HMO

  B. Employees of a group practice that has contracted with the HMO

  C. Compensated primarily through capitation

  D. Limited to primary care physicians (PCPs)

  Correct Answer: A

• Question 178:

  Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:

  The cost of hospitalization for two days Diagnostic tests performed in the hospital Trans

  A. ambulance and the diagnostic tests

  B. ambulance, the diagnostic tests, and the physician's professional services

  C. cost of hospitalization

  D. cost of hospitalization and the physician's professional services

  Correct Answer: D

• Question 179:

  The contract between the Honolulu MCO and Beverley Hills Hospital contains a 90 day cure provision. The Beverley Hills Hospital breached one of the contract requirements on July 31, 2004. The hospital remedied the problem by October 31, 2004. Which of the following answer is right?

  A. The contract would not be terminated as Beverley Hills hospital rectified the problem within 90 days.

  B. The contract would be terminated as Beverley Hills hospital was required to notify Honolulu MCO about the problem at least 90 days in advance.

  C. The contract would be terminated as Beverley Hills hospital was required to rectify the problem within 90 days.

  D. The contract would not be terminated as Beverley Hills hospital may escape adherence to the cure provision.

  Correct Answer: C

• Question 180:

  The criteria used to identify and measure healthcare quality are generally divided into three categories: structure, process, and outcomes measures. Structure measures, which relate to the nature and quality of the resources that a health plan has available

  A. length of time patients have to wait at the office to be seen by a provider

  B. percentage of plan physicians who are board-certified

  C. percentage of children receiving immunizations

  D. number of patients contracting an infection in the hospital

  Correct Answer: B