AHM-250 Online Practice Questions and Answers

Identify the CORRECT statement(s):

(A)

Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.

(B)

Gender of the group's participants has no effect on the likelihood of loss.

A.

All of the listed options

B.

B and C

C.

None of the listed options

D.

A and C

In claims administration terminology, a claims investigation is correctly defined as the process of

A. reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patterns

B. obtaining all the information necessary to determine the appropriate amount to pay on a given claim

C. routinely reviewing and processing a claim for either payment or denial

D. assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatment

From the answer choices below, select the response that correctly identifies the rating method that Mr. Sybex used and the premium rate PMPM that Mr. Sybex calculated for the Koster group.

A. Rating Method book rating Premium Rate PMPM $132

B. Rating Method book rating Premium Rate PMPM $138

C. Rating Method blended rating Premium Rate PMPM $132

D. Rating Method blended rating Premium Rate PMPM $138

The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On

A. hold all funds it receives on behalf of Alexander in trust

B. assume full responsibility for determining the claim payment procedures for the plan

C. assume full responsibility for ensuring that the health plan is administered properly

D. obtain from the federal government a certificate of authority designating the Cleopatra Group as a TPA

Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar-year deductible and includes a 20% coinsurance provision. When Ms. Urich was hospitalized, she incurred $3,000 in medical expenses that were covered by

A. 1900

B. 2000

C. 2400

D. 2500

One characteristic of disease management programs is that they typically

A. focus on individual episodes of medical care rather than on the comprehensive care of the patient over time

B. are used to coordinate the care of members with any type of disease, either chronic or nonchronic

C. focus on managing populations of patients who have a specific chronic illness or medical condition, but do not focus on patient populations who are at risk of developing such an illness or condition

D. use clinical practice processes to standardize the implementation of best practices among providers

Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason. Such a provision is kn

A. due process provision

B. cure provision

C. hold-harmless provision

D. risk-sharing provision

The contract between the Honolulu MCO and Beverley Hills Hospital contains a 90 day cure provision. The Beverley Hills Hospital breached one of the contract requirements on July 31, 2004. The hospital remedied the problem by October 31, 2004. Which of the following answer is right?

A. The contract would not be terminated as Beverley Hills hospital rectified the problem within 90 days.

B. The contract would be terminated as Beverley Hills hospital was required to notify Honolulu MCO about the problem at least 90 days in advance.

C. The contract would be terminated as Beverley Hills hospital was required to rectify the problem within 90 days.

D. The contract would not be terminated as Beverley Hills hospital may escape adherence to the cure provision.

Utilization data can be transmitted to the health plan manually, by telephone, or electronically. Compared to other methods of data transmittal, manual transmittal is generally

A. less cumbersome and labor intensive

B. faster and more accurate

C. more acceptable to physicians

D. subject to greater scrutiny by regulatory bodies

The provision of mental health and chemical dependency services is collectively known as behavioral healthcare. The following statements are about behavioral healthcare. Select the answer choice containing the correct statement.

A. In most preferred provider organizations (PPOs) and open access plans, plan members must receive a referral before accessing behavioral healthcare services from a specialist.

B. To manage the delivery of behavioral healthcare services, managed behavioral health organizations (MBHOs) typically use alternative treatment levels and alternative treatment methods rather than crisis intervention or alternative treatment settings.

C. Managed behavioral health organizations (MBHOs) typically are prohibited from negotiating with network providers for reduced fees in exchange for increased patient volume.

D. The treatment approaches for behavioral healthcare most often include drug therapy, psychotherapy, and counseling.

Utilization management techniques that most HMOs use for hospital providers include:

A. Discharge planning

B. Case management

C. Co-payment for office visits

D. A and B

The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms you have selected.

The Harbor Health Plan convened a litigation

A. a standing / ongoing

B. a standing / specific

C. an ad hoc / ongoing

D. an ad hoc / specific

Wellborne HMO provides health-related information to its plan members through an Internet Web site. Laura Knight, a Wellborne plan member, visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option

A. shared decision making

B. self-care

C. preventive care

D. triage

The Mirror Health Plan uses a form of computer/telephony integration (CTI) to manage telephone calls coming into its member services department. When a member calls the plan's central telephone number, a device answers the call with a recorded message and

A. a member outreach program

B. a complaint resolution procedure (CRP)

C. an automatic call distributor (ACD)

D. an interactive voice response (IVR) system

The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's

A. Hold all funds it receives on behalf of Titanium in trust.

B. Assume full responsibility for ensuring that the health plan is administered properly

C. Obtain from the federal government a certificate of authority designating the organization as a TPA.

D. Assume full responsibility for determining the claim payment procedures for the plan