AHIP AHIP Certification AHM-250 Questions & Answers

• Question 351:

  Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically

  A. are exempt from review by the Internal Revenue Service (IRS)

  B. are organized as stock companies for greater flexibility in raising capital

  C. rely on income from operations for the large cash outlays needed to fund long-term projects and expansion

  D. engage in lobbying or political activities in order to maintain their tax-exempt status

  Correct Answer: C

• Question 352:

  Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. Which best describes Emily's position?

  A. Community Representative

  B. Inside Director

  C. Outside Director

  D. None of these

  Correct Answer: B

• Question 353:

  Health plans require utilization review for all services administered by its participating physicians.

  A. True

  B. False

  Correct Answer: B

• Question 354:

  HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization is

  A. the use of physician practice guidelines

  B. the requirement of copayments for office visits

  C. capitation

  D. risk pools

  Correct Answer: B

• Question 355:

  If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info

  A. A Level One appeal, and the member has the right to a further appeal

  B. A Level Two appeal, and the reviewer's decision is final and binding

  C. An independent external appeal, and the member has the right to a further appeal

  D. Arbitration, and the reviewer's decision is final and binding

  Correct Answer: A

• Question 356:

  Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim

  A. A, B, C, and D

  B. A and C only

  C. A, B, and D only

  D. B, C, and D only

  Correct Answer: A

• Question 357:

  In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare health

  A. quality standards

  B. accreditation decisions

  C. standards of care

  D. performance measures

  Correct Answer: D

• Question 358:

  In 1999, the United States Congress passed the Financial Services Modernization Act, referred to as the Gramm-Leach-Bliley (GLB) Act. The primary provisions included under the GLB Act require financial institutions, including health plans, to take several

  A. Notify customers of any sharing of non-public personal financial information with nonaffiliated third parties.

  B. Prohibit customers from having the opportunity to 'opt-out' of sharing non-public personal financial information.

  C. Disclose to affiliates, but not to third parties, their privacy policies regarding the sharing of nonpublic personal financial information.

  D. Agree not to disclose personally identifiable financial information or personally identifiable health information.

  Correct Answer: A

• Question 359:

  As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im

  A. Benchmarking.

  B. Standard of care.

  C. An adverse event.

  D. Case-mix adjustment.

  Correct Answer: A

• Question 360:

  By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include

  A. coordinating care across a variety of benefits

  B. emphasizing preventive care by covering many preventive services either in full or with a small copayment

  C. offering its members access to wellness programs

  D. All of the above

  Correct Answer: D