AHIP AHIP Certification AHM-540 Questions & Answers

• Question 151:

  For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

  Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say

  A. that the construction of a data warehouse is quick and simple

  B. that a data warehouse addresses the problems associated with multiple data management systems

  C. that a data warehouse stores only current data

  D. all of the above

  Correct Answer: B

• Question 152:

  In order for a health plan's performance-based quality improvement programs to be effective, the desired outcomes must be

  A. achievable within a specified timeframe

  B. defined in terms of multiple results

  C. expressed in subjective, qualitative terms

  D. all of the above

  Correct Answer: A

• Question 153:

  Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

  A. must be offered as separate supplemental benefits or separate products

  B. lack clinical trials to evaluate their safety and effectiveness

  C. are not covered by state or federal consumer protection statutes

  D. focus on a specific illness, injury, or symptom rather than on the whole body

  Correct Answer: B

• Question 154:

  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.

  A. An health plan's CRPs reduce the likelihood of errors in decision making.

  B. CRPs typically provide for at least two levels of appeal for formal appeals.

  C. CRPs include only formal appeals and do not apply to informal complaints.

  D. Most complaints are resolved without proceeding through the entire CRP process.

  Correct Answer: C

• Question 155:

  Three general categories of coverage policy--medical policy, benefits administration policy, and administrative policy--are used in conjunction with purchaser contracts to determine a health plan's coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan's

  A. medical policy evaluates clinical services against specific benefits language rather than against scientific evidence

  B. benefits administration policy determines whether a particular service is experimental or investigational

  C. benefits administration policy focuses on both clinical and nonclinical coverage issues

  D. administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes

  Correct Answer: D

• Question 156:

  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

  A. Both 1 and 2

  B. 1 only

  C. 2 only

  D. Neither 1 nor 2

  Correct Answer: A

• Question 157:

  The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self- care most likely would not be appropriate.

  A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.

  B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.

  C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.

  D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

  Correct Answer: A

• Question 158:

  Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman's condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation care unit. Transferring Ms. Newman to the observation care unit most likely

  A. resulted in unnecessarily expensive charges for treatment

  B. prevented Ms. Newman from receiving immediate attention for her condition

  C. gave Ms. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region

  D. allowed clinical staff an opportunity to determine whether Ms. Newman required hospitalization without actually admitting her

  Correct Answer: D

• Question 159:

  The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

  Medical management programs often require the analysis of many types of data and information. __________________ is an automated process that analyzes variables to help detect patterns and relationships in the data.

  A. Unbundling

  B. Outsourcing

  C. Data mining

  D. Drilling down

  Correct Answer: C

• Question 160:

  The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC's standards and the type

  (s)

  of organizations to which these standards may be applied.

  A.

  Type(s) of Services-on-site services only Type(s) of Organization-health plans only

  B.

  Type(s) of Services-on-site services only Type(s) of Organization-any organization that performs case management functions

  C.

  Type(s) of Services-both telephonic and on-site services Type(s) of Organization-health plans only

  D.

  Type(s) of Services-both telephonic and on-site services Type(s) of Organization-any organization that performs case management functions

  Correct Answer: D