AHIP AHIP Certifications AHM-540 Questions & Answers

• Question 111:

  A health plan's coverage policies are linked to its purchaser contracts. The following statement(s) can

  correctly be made about the purchaser contract and coverage decisions: 1.In case of conflict between the purchaser contract and a health plan's medical policy or benefits administration policy, the contract takes precedence

  2.Purchaser contracts commonly exclude custodial care from their coverage of services and supplies 3.All of the criteria for coverage decisions must be included in the purchaser contract

  A. All of the above

  B. 1 and 2 only

  C. 2 only

  D. 3 only

  Correct Answer: B

• Question 112:

  DUR can be conducted prospectively, concurrently, or retrospectively. One true statement about prospective DUR is that it

  A. involves periodic audits of the medical records of a certain group of patients

  B. is based on historical data

  C. focuses on the drug therapy for a single patient rather than overall usage patterns

  D. is conducted by physicians, without input from pharmacists

  Correct Answer: C

• Question 113:

  The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.

  The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.

  A. rebate / is

  B. rebate / is not

  C. price discount / is

  D. price discount / is not

  Correct Answer: D

• Question 114:

  The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:

  Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program's recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks

  From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2

  A. Measure 1-true outcome measure Measure 2-true outcome measure

  B. Measure 1-true outcome measure Measure 2-intermediate outcome measure

  C. Measure 1-intermediate outcome measure Measure 2-true outcome measure

  D. Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

  Correct Answer: C

• Question 115:

  The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  A. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.

  B. UR evaluates whether the services recommended by a member's provider are covered under the benefit plan.

  C. UR recommends the procedures that providers should perform for plan members.

  D. A health plan's UR program is usually subject to review and approval by the state insurance and/or health departments.

  Correct Answer: C

• Question 116:

  Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

  A. effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan

  B. effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy

  C. the effectiveness of an action plan is typically measured with a concurrent evaluation

  D. an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions

  Correct Answer: B

• Question 117:

  Determine whether the following statement is true or false:

  The delegation of medical management functions to providers can occur without the transfer of financial risk.

  A. True

  B. False

  Correct Answer: A

• Question 118:

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

  TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

  A. appeals / TRICARE contractor

  B. appeals / Area Field Office

  C. grievances / TRICARE contractor

  D. grievances / Area Field Office

  Correct Answer: A

• Question 119:

  The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.

  Under a delegation arrangement, the (delegate / delegator) is responsible for performing the delegated function according to established standards, and the (delegate / delegator) is ultimately accountable for any deficiencies in the performance of the function.

  A. delegate / delegate

  B. delegate / delegator

  C. delegator / delegate

  D. delegator / delegator

  Correct Answer: B

• Question 120:

  The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

  A. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.

  B. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients.

  C. In order to serve as a hospitalist, a physician must have a background in critical care medicine.

  D. Hospitalists typically spend at least one-quarter of their time in a hospital setting.

  Correct Answer: D