AHIP AHIP Certifications AHM-540 Questions & Answers

• Question 71:

  Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden

  A. must pay the entire cost of the examination

  B. must obtain a referral to a dentist from her primary care provider (PCP)

  C. can schedule the examination without preauthorization of payment by the DHMO

  D. can schedule an unlimited number of examinations and cleanings per year

  Correct Answer: C

• Question 72:

  When conducting performance assessment, a health pln may classify the key processes associated with its services into the following categories: high-risk, high-volume, problem- prone, and high-cost.

  The following statements are about this classification of processes. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  A. In some instances, relatively inexpensive processes can qualify as high-cost processes.

  B. Each process must be classified into a single category.

  C. High-risk processes most often involve medical interventions or treatment plans for acute illnesses or case management processes for complex conditions.

  D. Administrative processes such as scheduling appointments are examples of high- volume processes.

  Correct Answer: B

• Question 73:

  Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.

  If Ms. Stanley agrees to the generic substitution, she will receive a drug that

  A. has not been tested for safety and efficacy in large clinical trials

  B. is available without a prescription at a reasonable cost

  C. has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective

  D. contains active ingredients that are identical to those of the prescribed brand-name drug

  Correct Answer: D

• Question 74:

  In most health plans, the formulary system is developed and managed by a PandT committee. The PandT committee is responsible for

  A. evaluating and selecting drugs for inclusion in the formulary

  B. overseeing the manufacture, distribution, and marketing of prescription drugs

  C. certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs

  D. all of the above

  Correct Answer: A

• Question 75:

  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.

  Due to competitive pressures and consumer demand, many health plans now offer direct access or open access products. Under a direct access product, a member is (required / not required) to select a primary care provider (PCP), and is (required / not required) to obtain a referral from a PCP or the health plan before visiting a network specialist.

  A. required / required

  B. required / not required

  C. not required / required

  D. not required / not required

  Correct Answer: B

• Question 76:

  The following statements are about health plans' use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

  A. One advantage of EDI over manual data management systems is improved data integrity.

  B. EDI may use the Internet as the communication link between the participating parties.

  C. EDI involves back-and-forth exchanges of information concerning individual transactions.

  D. The data format for EDI is agreed upon by the sending and receiving parties.

  Correct Answer: C

• Question 77:

  The following statement(s) can correctly be made about the hospitalist approach to inpatient care management:

  1.Management of inpatient care by hospitalists may significantly reduce the length of stay and the total costs of care for a hospital admission

  2.Most health plans that use hospitalists do so through a voluntary hospitalist program

  3.A

  hospitalist's familiarity with utilization management (UM) and quality management (QM) standards for inpatient care may reduce unnecessary variations in care and improve clinical outcomes

  A.

  All of the above

  B.

  1 and 2 only

  C.

  1 and 3 only

  D.

  2 only

  Correct Answer: A

• Question 78:

  The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  A. The use of a signed consent authorization form is consistent with accrediting agency standards for patient privacy and confidentiality of medical information.

  B. Case management that is initiated after a member has incurred substantial medical expenses is more likely to be viewed as a tool to cut costs rather than to improve outcomes.

  C. Health plan documents indicating that any case management delegates are separate, independent entities may reduce an health plan's exposure to risk.

  D. A case management file cannot be used to support the health plan's position in the event of a lawsuit.

  Correct Answer: D

• Question 79:

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

  The Balanced Budget Act (BBA) of 1997 established the use of ___________ to determine coverage of emergency services for Medicare and Medicaid enrollees in health plans.

  A. utilization management standards

  B. the prudent layperson standard

  C. preauthorization

  D. diagnosis-based retrospective review

  Correct Answer: B

• Question 80:

  Outcomes management is a tool that health plans use to maximize all the results associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:

  1.The goal of outcomes management is to identify and implement treatments that are cost- effective and deliver the greatest value

  2.Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

  A. Both 1 and 2

  B. 1 only

  C. 2 only

  D. Neither 1 nor 2

  Correct Answer: A