AHIP AHIP Certifications AHM-540 Questions & Answers

• Question 61:

  Determine whether the following statement is true or false:

  Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.

  A. True

  B. False

  Correct Answer: B

• Question 62:

  The Mental Health Parity Act (MHPA) of 1996 is a federal law that establishes requirements for behavioral healthcare coverage for group plan members. The MHPA

  A. requires health plans to offer mental health benefits to all eligible members

  B. prohibits health plans that offer mental health benefits from imposing lower annual or lifetime dollar limits on mental illnesses than they do on physical illnesses

  C. provides an exemption for health plans that can demonstrate cost savings of more than 1 percent

  D. prohibits health plans from limiting the number of outpatient visits or inpatient days covered under the plan

  Correct Answer: B

• Question 63:

  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.

  One component of UR is an administrative review. An administrative review compares the proposed medical care to the applicable (medical policy / contract provision). This type of review (can / cannot) be conducted by a nonclinical staff member.

  A. medical policy / can

  B. medical policy / cannot

  C. contract provision / can

  D. contract provision / cannot

  Correct Answer: C

• Question 64:

  Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

  A. cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations

  B. diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care

  C. patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes

  D. the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

  Correct Answer: D

• Question 65:

  Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by

  A. severing the link between Medicaid and public assistance

  B. eliminating the need for applications for Medicaid and public assistance

  C. allowing states to provide healthcare benefits to groups outside the traditional Medicaid population

  D. providing supplemental funding for dual eligibles in the form of five-year block grants

  Correct Answer: A

• Question 66:

  The following statements are about health plans' development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  A. Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests.

  B. Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not.

  C. The medical policy development process includes both a clinical and an operational review of a proposed medical policy.

  D. The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.

  Correct Answer: A

• Question 67:

  Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs).

  Unlike other coverage options, CCPs

  A. provide only those benefits covered by Medicare Part A and Part B

  B. are not subject to federal or state regulation

  C. place primary care at the center of the delivery system

  D. are structured as indemnity plans

  Correct Answer: C

• Question 68:

  The Harbor Health Plan's formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as

  A. generic substitution, and prescriber approval is not required

  B. generic substitution, and prescriber approval is always required

  C. therapeutic substitution, and prescriber approval is not required

  D. therapeutic substitution, and prescriber approval is always required

  Correct Answer: D

• Question 69:

  Patient safety and medical errors are important concerns for both quality management (QM) and risk management. The following statement(s) can correctly be made about medical errors:

  1.The complexity of modern medicine and healthcare delivery systems increases patients' exposure to the risks of medical errors

  2.Licensing boards for healthcare professionals in all states provide a consistent system of quality oversight and accountability

  3.Provider compliance with internal incident reporting requirements is low

  A. All of the above

  B. 1 and 2 only

  C. 1 and 3 only

  D. 3 only

  Correct Answer: C

• Question 70:

  One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the

  A. appropriate dosages, duration of treatment, and other elements related to the use of a particular drug

  B. actual prescribing and dispensing patterns for a particular drug

  C. types of diseases, conditions, or patients for which a drug should be used

  D. cost-effectiveness of all possible drug treatments for a particular condition

  Correct Answer: A