AHIP Network Management - AHM-530 Exam Practice Test
Question 1
The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:
The Apex Company, a managed vision care organization (MVCO)
The Baxter Managed Behavioral Healthcare Organization (MBHO)
The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA's accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for
The Apex Company, a managed vision care organization (MVCO)
The Baxter Managed Behavioral Healthcare Organization (MBHO)
The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA's accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for
Correct Answer: A
Question 2
The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
If Gladspell's per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as
If Gladspell's per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as
Correct Answer: C
Question 3
Factors that are likely to indicate increased health plan market maturity include:
Correct Answer: A
Question 4
Grant Pelham is covered by both a workers' compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
The provider network that Shipwright uses to furnish services for its workers' compensation program will most likely
The provider network that Shipwright uses to furnish services for its workers' compensation program will most likely
Correct Answer: A
Question 5
The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.
Correct Answer: C
Question 6
Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as
Correct Answer: B
Question 7
Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:
Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level
Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level
The use of a physician incentive plan creates substantial risk for
Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level
Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level
The use of a physician incentive plan creates substantial risk for
Correct Answer: D
Question 8
An health plan's contract negotiation team consists of several skilled individuals from different areas. At least one of the members is responsible for evaluating the wording of specific clauses to ensure that the health plan's rights are protected, as well as to ensure that the contract is in compliance with state and federal regulation. By profession, this member of the contract negotiation team is typically
Correct Answer: D
Question 9
Salvatore Arris is a member of the Crescent Health Plan, which provides its members with a full range of medical services through its provider network. After suffering from debilitating headaches for several days, Mr. Arris made an appointment to see Neal Prater, a physician's assistant in the Crescent network who provides primary care under the supervision of physician Dr. Anne Hunt. Mr. Prater referred Mr. Arris to Dr. Ginger Chen, an ophthalmologist, who determined that Mr. Arris' symptoms were indicative of migraine headaches. Dr. Chen prescribed medicine for Mr. Arris, and Mr. Arris had the prescription filled at a pharmacy with which Crescent has contracted. The pharmacist, Steven Tucker, advised Mr. Arris to take the medicine with food or milk. In this situation, the person who functioned as an ancillary service provider is
Correct Answer: D
Question 10
The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Walton's MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for
Correct Answer: B
