AHM-250 Online Practice Questions and Answers

A particular health plan offers a higher level of benefits for services provided in-network than for out-ofnetwork services. This health plan requires preauthorization for certain medical services.

With regard to the steps that the health plan's claims e

A. should assume that all services requiring preauthorization have been preauthorized

B. should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claim

C. need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefits

D. need not determine whether the member is covered by another health plan that allows for coordination of benefits

From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy

A. Health plans and their providers are obligated not to harm their members

B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group

C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members

D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives

The criteria used to identify and measure healthcare quality are generally divided into three categories: structure, process, and outcomes measures. Structure measures, which relate to the nature and quality of the resources that a health plan has available

A. length of time patients have to wait at the office to be seen by a provider

B. percentage of plan physicians who are board-certified

C. percentage of children receiving immunizations

D. number of patients contracting an infection in the hospital

One distinction that can be made between a staff model HMO and a group model HMO is that, in a staff model HMO, participating physicians are Back to Top

A. Employees of the HMO

B. Employees of a group practice that has contracted with the HMO

C. Compensated primarily through capitation

D. Limited to primary care physicians (PCPs)

High deductible health plans (HDHP) are characterized by all of the following features except

A. A HDHPs have a higher deductible than other traditional insurance products such as HMOs and PPOs.

B. HDHPs generally cost more than traditional heathcare coverage.

C. Some HDHPs cover preventive care on a first-dollar coverage basis.

D. All of the above

Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review?

A. Cost per procedure

B. Concurrent review

C. Cost of review

D. Access requirements

Which of the following is WRONG?

A. Computer Based Patient Records Institute (CPRI) developed the standards for digital imaging of xrays.

B. HL7 developers focuses on interchange of Clinical Health Data

C. ANSI, a voluntary national standards organization, creates a consensus based process by which fair and equitable standards can be developed and serves as a legitmizer of standards.

D. American Health Information Management Association focuses on EDI standards for exchange of clinical data

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 statements below describe technology used by two MCOs to respond to incoming telephone calls:

The Morton MCO uses an automated system that answers telephone calls with recorded or synthesized speech and prompts the caller to respond to a menu of option

A. Autumn's device is best described as an interactive voice response (IVR) system.

B. Both Morton's system and Autumn's device are applications of computer/telephony integration (CTI).

C. Morton's system is best described as an automatic call distributor (ACD).

D. Morton's system can be correctly characterized as an expert system.

Which of the following statements about the Title VII of the Civil Rights Act is WRONG?

A. Employers with more than 15 employees engaged in interstate commerce need to comply

B. Pregnancy Discrimination Act (an amendment to this act) requires health plans to provide coverage during childbirth and related medical conditions on the same basis as they provide coverage for other medical conditions

C. Allows HMOs to set different policies for people from different races, religions, sex or national origin to safeguard their interests.

D. Protects all employees