How Many Questions Of AHM-540 Dumps Questions

NEW QUESTION 1
By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as

• A. utilization management (UM)
• B. quality management (QM)
• C. care management
• D. clinical practice management

Answer: D

NEW QUESTION 2
The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.
Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

• A. activities of daily living / functional status
• B. activities of daily living / health status
• C. instrumental activities of daily living / functional status
• D. instrumental activities of daily living / health status

Answer: A

NEW QUESTION 3
Most health plans require a PCP referral or precertification for CAM benefits.

• A. True
• B. False

Answer: B

NEW QUESTION 4
The Westchester Health Plan classifies its key processes into the following categories: high-risk, high-volume, problem-prone, and high-cost. Westchester also prioritizes the categories in terms of importance. The process category that Westchester most likely ranks highest in importance is

• A. High-risk processes
• B. High-volume processes
• C. Problem-prone processes
• D. High-cost processes

Answer: A

NEW QUESTION 5
To improve members’ abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.

• A. The primary role of telephone triage clinical staff is to diagnose the caller’s condition and give medical advice.
• B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.
• C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.
• D. A telephone triage program may also include a self-care component.

Answer: B

NEW QUESTION 6
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select the term or phrase in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms or phrases you have chosen.
TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

• A. appeals / TRICARE contractor
• B. appeals / Area Field Office
• C. grievances / TRICARE contractor
• D. grievances / Area Field Office

Answer: A

NEW QUESTION 7
A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
* 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence
* 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
* 3. All of the criteria for coverage decisions must be included in the purchaser contract

• A. All of the above
• B. 1 and 2 only
• C. 2 only
• D. 3 only

Answer: B

NEW QUESTION 8
Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which
* 1.A significant percentage of those treated with the initial therapy will require the second therapy
* 2.The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: C

NEW QUESTION 9
The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:
Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks
From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-

• A. Measure 1-true outcome measure Measure 2-true outcome measure
• B. Measure 1-true outcome measure Measure 2-intermediate outcome measure
• C. Measure 1-intermediate outcome measure Measure 2-true outcome measure
• D. Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

Answer: C

NEW QUESTION 10
Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include
* 1. The period prior to a hospital admission
* 2. The period following discharge from a hospital

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: A

NEW QUESTION 11
Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

• A. provide only those benefits covered by Medicare Part A and Part B
• B. are not subject to federal or state regulation
• C. place primary care at the center of the delivery system
• D. are structured as indemnity plans

Answer: C

NEW QUESTION 12
Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden

• A. must pay the entire cost of the examination
• B. must obtain a referral to a dentist from her primary care provider (PCP)
• C. can schedule the examination without preauthorization of payment by the DHMO
• D. can schedule an unlimited number of examinations and cleanings per year

Answer: C

NEW QUESTION 13
This agency oversees the Federal Employee Health Benefits Program (FEHBP).

• A. Health Resources and Services Administration (HRSA)
• B. Office of Personnel Management (OPM)
• C. Department of Health and Human Services (HHS)
• D. Department of Justice (DOJ)

Answer: B

NEW QUESTION 14
The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as

• A. vicarious liability
• B. fraud
• C. a tying arrangement
• D. subdelegation

Answer: A

NEW QUESTION 15
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

Answer: D

NEW QUESTION 16
Determine whether the following statement is true or false:
The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

• A. True
• B. False

Answer: B

NEW QUESTION 17
The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

• A. One advantage of EDI over manual data management systems is improved data integrity.
• B. EDI may use the Internet as the communication link between the participating parties.
• C. EDI involves back-and-forth exchanges of information concerning individual transactions.
• D. The data format for EDI is agreed upon by the sending and receiving parties.

Answer: C

NEW QUESTION 18
The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:
Administrative costs for case management ..........$40,000
Actual medical care expenses for patients under case management ..........$680,000
Projected medical care expenses for the same patients without case management
..........$900,000
This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

• A. 0.71/1
• B. 0.80/1
• C. 5.50/1
• D. 1.25/1

Answer: C

NEW QUESTION 19
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