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AHIP AHM-540 - Questions & Answers

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Question 1
Single choice

One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A.

A HIN may afford a health plan better measurements of outcomes and provider performance.

B.

The use of a HIN typically increases a health plan's exposure to liability for poor care.

C.

Most HINs are Internet-based rather than built on proprietary computer networks.

D.

Currently, the majority of health plans do not have HINs that are capable of transferring medical
records among their network providers.

Question 2
Single choice

One true statement about state regulation of case management activities is that the majority of states

A.

have enacted laws that list specific quality management requirements for a case management program

B.

consider case management files to be medical records that must be retained for a specified length of time

C.

view case management similarly and follow similar patterns with their laws and regulations

D.

have enacted laws or regulations requiring licensure or certification of case managers

Question 3
Single choice

CMS has developed two prototype programs--Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project--to deliver healthcare services to Medicare beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

A.

PACE-annual limits on benefits for nursing home and community-based care SHMO-no limits on long-term care benefits

B.

PACE-provide long-term care only SHMO-provide acute and long-term care

C.

PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older

D.

PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO-enrollment open to all Medicare beneficiaries

Question 4
Single choice

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

Question 5
Single choice

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

Medical management programs often require the analysis of many types of data and information.
__________________ is an automated process that analyzes variables to help detect patterns and relationships in the data.

A.

Unbundling

B.

Outsourcing

C.

Data mining

D.

Drilling down

Question 6
Single choice

Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman's condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation care unit. Transferring Ms. Newman to the
observation care unit most likely

A.

resulted in unnecessarily expensive charges for treatment

B.

prevented Ms. Newman from receiving immediate attention for her condition

C.

gave Ms. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region

D.

allowed clinical staff an opportunity to determine whether Ms. Newman required hospitalization without actually admitting her

Question 7
Single choice

The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self-care most likely would not be appropriate.

A.

Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.

B.

Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.

C.

Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.

D.

Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

Question 8
Single choice

The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):

1. FEHBP plan members who have exhausted the health plan's usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM)

2. All health plans that cover federal employees are required to develop and implement patient safety initiatives

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

Question 9
Single choice

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

Question 10
Single choice

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.

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