Exam Code: AHM-540 (Practice Exam Latest Test Questions VCE PDF)
Exam Name: Medical Management
Certification Provider: AHIP
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NEW QUESTION 1
The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

  • A. detailing
  • B. cognitive services
  • C. counter detailing
  • D. drug efficacy study implementation (DESI)

Answer: C

NEW QUESTION 2
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. _________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.

  • A. A clinical practice guideline (CPG)
  • B. Medical policy
  • C. Benefits administration policy
  • D. A standard of care

Answer: B

NEW QUESTION 3
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.

Answer: C

NEW QUESTION 4
The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
* 1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
* 2.The National Committee for Quality Assurance (NCQA)
* 3.The American Accreditation HealthCare Commission/URAC (URAC)

  • A. All of the above
  • B. 1 and 2 only
  • C. 2 and 3 only
  • D. 1 only

Answer: B

NEW QUESTION 5
The following statements are about medical management considerations for dental care. Select the answer choice containing the correct statement.

  • A. Managed dental care organizations are regulated at the state rather than the federal level.
  • B. Dental care differs from medical care in that most dental care is provided by specialists.
  • C. Dental preferred provider organizations (Dental PPOs) are subject to more regulation than are dental health maintenance organizations (DHMOs).
  • D. Managed dental plans are accredited by the National Association of Dental Plans (NADP).

Answer: A

NEW QUESTION 6
Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.
The document that Mr. Farrell is using to communicate his end-of-life healthcare wishes to his family is known as a

  • A. medical power of attorney
  • B. patient assessment and care plan
  • C. living will
  • D. healthcare proxy

Answer: C

NEW QUESTION 7
State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on

  • A. Medicare and TRICARE programs
  • B. Medicaid and workers’ compensation programs
  • C. Medicare and Medicaid programs
  • D. TRICARE and workers’ compensation programs

Answer: B

NEW QUESTION 8
Health plans arrange for the delivery of various levels of healthcare, including
* 1.Emergency care
* 2. Urgent care
* 3. Primary care delivered in a provider’s office
In a ranking of these levels of care according to cost, beginning with the least expensive level of care and ending with the most expensive level of care, the correct order would be

  • A. 1—2—3
  • B. 2—3—1
  • C. 3—1—2
  • D. 3—2—1

Answer: D

NEW QUESTION 9
The following statement(s) can correctly be made about accrediting agency standards for delegation:
* 1. The National Committee for Quality Assurance (NCQA) allows health plans to delegate
all medical management functions, including the responsibility to perform delegation oversight activities
* 2. In some cases, accreditation standards for delegation oversight are reduced if the delegate has already been certified or accredited by the delegator’s accrediting agency

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

Answer: C

NEW QUESTION 10
The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:
Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks
From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-

  • A. Measure 1-true outcome measure Measure 2-true outcome measure
  • B. Measure 1-true outcome measure Measure 2-intermediate outcome measure
  • C. Measure 1-intermediate outcome measure Measure 2-true outcome measure
  • D. Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

Answer: C

NEW QUESTION 11
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

Answer: D

NEW QUESTION 12
Determine whether the following statement is true or false:
Independent review organizations (IROs) can mediate disputes and offer advisory opinions to health plans on UR issues, but they cannot render binding decisions on appeals.

  • A. True
  • B. False

Answer: B

NEW QUESTION 13
Administrative action plans are used when performance problems or opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:
* 1.Administrative action plans allow health plans to coordinate management activities
* 2.One function of administrative action plans is to integrate service across all levels of the organization
* 3.Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health

  • A. All of the above
  • B. 1 and 2 only
  • C. 1 and 3 only
  • D. 2 and 3 only

Answer: B

NEW QUESTION 14
The Noble Health Plan conducted a cost/benefit analysis of the following four prescription drugs:
BenefitCost Drug A$525$350 Drug B$450$250
Drug C$400$200 Drug D$350$100
According to this analysis, the drug that represents the most efficient use of resources is

  • A. Drug A
  • B. Drug B
  • C. Drug C
  • D. Drug D

Answer: D

NEW QUESTION 15
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

Answer: A

NEW QUESTION 16
Health plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say
* 1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days
* 2. That the timeframe is accelerated for expedited appeals
* 3. That the review period begins when the appeal arrives at a health plan

  • A. All of the above
  • B. 1 and 2 only
  • C. 1 and 3 only
  • D. 2 and 3 only

Answer: D

NEW QUESTION 17
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 18
The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.
Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

  • A. activities of daily living / functional status
  • B. activities of daily living / health status
  • C. instrumental activities of daily living / functional status
  • D. instrumental activities of daily living / health status

Answer: A

NEW QUESTION 19
Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.
The following statements are about accreditation. Select the answer choice containing the correct statement.

  • A. At the request of health plans, accrediting agencies gather the data needed for accreditation.
  • B. Most purchasers and consumers review accreditation results when making decisions to purchase or enroll in a specific health plan.
  • C. Accreditation is typically conducted by independent, not-for-profit organizations.
  • D. All health plans are required to participate in the accreditation process.

Answer: C

NEW QUESTION 20
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

Answer: B

NEW QUESTION 21
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