AHM-540 | High Value AHIP AHM-540 Actual Exam Online

NEW QUESTION 1
Emilio Martinez, a member of the Bloom Health Plan, has recently been diagnosed with prostate cancer by his physician, Dr. Robert Cohen. Mr. Martinez has decided to participate in Bloom’s shared decision-making program for prostate cancer. On the basis of this information, it is most likely correct to say
* 1. That verification of Mr. Martinez’s understanding about his care options protects both Dr. Cohen and Bloom against charges of malpractice
* 2. That Mr. Martinez and Dr. Cohen will discuss the care options available to Mr. Martinez, but the ultimate decision about care is up to Dr. Cohen

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: D

NEW QUESTION 2
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. _____ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.

• A. Accessibility
• B. Effectiveness
• C. Acceptability
• D. Efficiency

Answer: D

NEW QUESTION 3
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of

• A. a cosmetic service
• B. an investigational service
• C. an off-label use
• D. a quality-of-life service

Answer: C

NEW QUESTION 4
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.

Answer: C

NEW QUESTION 5
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.

Answer: B

NEW QUESTION 6
Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include
* 1. The period prior to a hospital admission
* 2. The period following discharge from a hospital

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: A

NEW QUESTION 7
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

Answer: D

NEW QUESTION 8
Determine whether the following statement is true or false:
The utilization review (UR) process produces the greatest number of case management referrals.

• A. True
• B. False

Answer: A

NEW QUESTION 9
Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

• A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation
• B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions
• C. cover only services delivered in an acute inpatient setting
• D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

Answer: B

NEW QUESTION 10
One method that health plans use to address provider compliance with formularies is academic detailing.

• A. True
• B. False

Answer: A

NEW QUESTION 11
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

Answer: D

NEW QUESTION 12
In most health plans, the formulary system is developed and managed by a P&T committee. The P&T 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

Answer: A

NEW QUESTION 13
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

Answer: C

NEW QUESTION 14
The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid Services (CMS) requires compliance with QAPI from

• A. both Medicare+Choice plans and Medicaid health plans
• B. Medicare+Choice plans only
• C. Medicaid health plans only
• D. neither Medicare+Choice plans nor Medicaid health plans

Answer: B

NEW QUESTION 15
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

Answer: D

NEW QUESTION 16
The paragraph below contains two pairs of terms in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.

• A. Internal / internal
• B. Internal / external
• C. External / internal
• D. External / external

Answer: D

NEW QUESTION 17
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