AHIP AHM-530 - Network Management Exam
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Total 202 questions
Question #11 (Topic: Topic 1)
The National Committee for Quality Assurance (NCQA) has integrated accreditation with
Health Employer Data and Information Set (HEDIS) measures into a program called
Accreditation 99. One statement that can correctly be made about these accreditation
standards is that
Health Employer Data and Information Set (HEDIS) measures into a program called
Accreditation 99. One statement that can correctly be made about these accreditation
standards is that
A. Health plans are required by law to report HEDIS results to NCQA
B. HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
C. Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
D. HEDIS includes measures of a health plans effectiveness of care rather than its cost of care
Answer: C
Question #12 (Topic: Topic 1)
If a third party is responsible for injuries to a plan member of the Hope Health Plan, then
Hope has a contractual right to file a claim for the resulting healthcare costs against the
third party. This contractual right to recovery from the third party is known as
Hope has a contractual right to file a claim for the resulting healthcare costs against the
third party. This contractual right to recovery from the third party is known as
A. Subrogation
B. Partial capitation
C. Coordination of benefits
D. Aremedy provision
Answer: A
Question #13 (Topic: Topic 1)
One reason that an health plan would want to use the actual acquisition cost (AAC) pricing
system to calculate its drug costs is that, of the systems commonly used to calculate drug
costs, the AAC system
system to calculate its drug costs is that, of the systems commonly used to calculate drug
costs, the AAC system
A. Provides the lowest level of cost for the health plan
B. Most closely represents what pharmacies are actually charged for prescription drugs
C. Offers the best control over multiple-source pharmaceutical products
D. Is the least expensive pricing system for the health plan to implement
Answer: A
Question #14 (Topic: Topic 1)
Network managers rely on a health plans claims administration department for much of the
information needed to manage the performance of providers who are not under a capitation
arrangement. Examining claims submitted to a health plans claims administration
department enables the health plan to
information needed to manage the performance of providers who are not under a capitation
arrangement. Examining claims submitted to a health plans claims administration
department enables the health plan to
A. determine the number of healthcare services delivered to plan members
B. monitor the types of services provided by the health plan’s entire provider network
C. evaluate providers practice patterns and compliance with the health plans procedures for the delivery of care
D. all of the above
Answer: D
Question #15 (Topic: Topic 1)
One true statement about the compensation arrangement known as the case rate system
is that, under this system,
is that, under this system,
A. Providers stand to gain or lose based on the number and types of treatments used for each case
B. Providers have no incentives to take an active role in managing cost and utilization
C. Payors cannot adjust standard case rates to reflect the severity of the patients condition or complications that arise from multiple medical problems
D. Payors have the opportunity to benefit from the provider’s cost savings
Answer: A
