AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 181:

  The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:

  A. An administrative review must be conducted by a health plan staff member who is a medical professional.

  B. The primary purpose of an administrative review is to evaluate the appropriateness of a proposed medical service.

  C. UR staff members typically conduct a medical review of a proposed medical service before they conduct an administrative review for that same service.

  D. One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.

  Correct Answer: D

• Question 182:

  The Blaine Healthcare Corporation seeks to manage its quality by first identifying the best practices and best outcomes for a given procedure. Blaine can then determine areas in which it can emulate the best practices in order to equal or surpass the best

  A. provider profiling

  B. benchmarking

  C. peer review

  D. quality assessment

  Correct Answer: B

• Question 183:

  Mr. George Bush is covered by a PBM plan that uses a closed formulary. This indicates that

  A. he can receive coverage for pharmaceuticals only if they are on the PBM plan's preferred list of drugs

  B. he must receive all of his pharmaceuticals from a mail-order pharmacy program

  C. he can receive coverage for pharmaceuticals that are on the PBM plan's preferred list of drugs, as well as for pharmaceuticals that are not on the preferred list

  D. the PBM plan cannot receive a rebate on any pharmaceuticals it obtains from the pharmaceutical facture

  Correct Answer: A

• Question 184:

  The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be

  A. Credentialing

  B. Accreditation

  C. A sentinel event

  D. A screening program

  Correct Answer: A

• Question 185:

  One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it A. exempted HMOs from all state licensure requirements.

  B. required all employers that offered healthcare coverage to their employees to offer only one type of federally qualified HMO.

  C. eliminated funding that supported the planning and start-up phases of new HMOs.

  D. established a process by which HMOs could obtain federal qualification

  Correct Answer: D

• Question 186:

  Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves

  A. ascertaining that physicians in the plan have the necessary and appropriate credentials to prescribe medications

  B. compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categories

  C. monitoring patient-specific drug problems through concurrent and retrospective review

  D. establishing protocols that require physicians to obtain certification of medical necessity prior to drug dispensing

  Correct Answer: B

• Question 187:

  The administrative simplification standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit

  A. all health plans, healthcare providers, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an individual's written consent

  B. patients from requesting that restrictions be placed on the accessibility and use of protected health information

  C. transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorization

  D. patients from accessing their medical records and requesting the amendment of incorrect or incomplete information

  Correct Answer: D

• Question 188:

  One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the

  A. The Centers for Medicare and Medicaid Services (CMS) must approve all marketing materials used by health plans to market health plan products to the Medicare population

  B. managed Medicare plans typically require Medicare beneficiaries to purchase Medigap insurance to supplement gaps in coverage

  C. managed Medicare plans can refuse to cover persons with certain health problems

  D. the CMS prohibits health plans from using telemarketing to market health plan products to the Medicare population

  Correct Answer: B

• Question 189:

  Khalyn Drury's employer includes managed dental care in its employee benefits package. During open enrollment, Ms. Drury enrolled in the dental plan, which provides dental services to its members in exchange for a prepayment (the premium). Dental services

  A. dental preferred provider organization (PPO)

  B. traditional fee-for-service (FFS) dental plan

  C. plan with a dental point of service (POS) option

  D. dental health maintenance organization (DHMO)

  Correct Answer: D

• Question 190:

  One true statement regarding ethics and laws is that the values of a community are reflected in

  A. both ethics and laws, and both ethics and laws are enforceable in the court system

  B. both ethics and laws, but only laws are enforceable in the court system

  C. ethics only, but only laws are enforceable in the court system

  D. laws only, but both ethics and laws are enforceable in the court system

  Correct Answer: B