AHM-540 Online Practice Questions and Answers

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.

Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.

A. This questionnaire was designed specifically for use by health plans.

B. Each health plan must use the same form of the questionnaire, with no additions or modifications.

C. This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults.

D. All of the above statements are correct.

The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.

B. UR evaluates whether the services recommended by a member's provider are covered under the benefit plan.

C. UR recommends the procedures that providers should perform for plan members.

D. A health plan's UR program is usually subject to review and approval by the state insurance and/or health departments.

Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types ofperformance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A. The most widely used structure measures relate to physician education and training.

B. One advantage of structure measures over process measures is that structures are often linked directly to healthcare outcomes.

C. Process measures are useful in identifying underuse, overuse, and inappropriate use of services.

D. One disadvantage of outcome measures is that they can be influenced by factors outside the control of the health plan.

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

One way that health plans can make their benefits more appealing to employers and employees is to offer coverage for specialty services. It is correct to say that specialty services typically

A. involve the same types of providers and delivery systems as do standard medical services

B. are a subset of a health plan's standard medical-surgical services

C. are not monitored by health plans for quality or utilization

D. require specialized knowledge for service delivery and management

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans' efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

A. standard medical-surgical services

B. mental health and substance abuse services

C. services offered to Medicare enrollees as optional supplementary benefits

D. all of the above

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

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

The following statement(s) can correctly be made about utilization guidelines:

1.When developing utilization guidelines, health plans balance evidence-based criteria with experience-based criteria

2.Utilization guidelines indicate when a UR nurse should refer a decision to a physician reviewer

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2