AHM-250 試験問題を無料オンラインアクセス

Consolidation of patient information in a single location as can be used by independent providers is an example of

• A.None of the above
• B.Business Integration
• C.Structural Integration
• D.Operational Integration

Some states mandate that an independent enrollment broker or benefits counselor contractor selected by the state must manage enrollment of the eligible Medicaid population into managed care. In other states a health plan can engage independent brokers and

• A.Health plans typically are allowed to medically underwrite all individual market customers who are covered by Medicare and can refuse to cover such customers.
• B.To promote a health plan product to the individual market, health plans typically use captive agents who give sales presentations to potential customers, rather than using promotion tools such as direct mail, telemarketing, or advertising.
• C.Many states have regulations that prohibit health plans from using door-to-door and/or telephone solicitation to market health plan products to the Medicaid population.
• D.Health plans are never allowed to medically underwrite individual market customers who are under age 65.

The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:

• A.One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.
• B.The primary purpose of an administrative review is to evaluate the appropriateness of a proposed medical service.
• C.UR staff members typically conduct a medical review of a proposed medical service before they conduct an administrative review for that same service.
• D.An administrative review must be conducted by a health plan staff member who is a medical professional.

Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:

• A.Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract.
• B.Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives Dr. Aldridge at least 90-days' notice of its intent to terminate the contract.
• C.Give Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.
• D.State that Dr. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.

The following statements are about the various Health Plan Accountability Models adopted by the NAIC.

• A.The Health Carrier Grievance Procedure Model Act requires all health carriers to maintain a first-level grievance review, but it does not require any second-level review
• B.Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be required to hold covered persons harmless against provider collections and provide continued coverage for uncompleted treatment in the event of plan insolvency
• C.The Quality Assessment and Improvement Model Act exempts closed plans from implementing a quality improvement program.
• D.According to the Health Care Professional Credentialing Verification Model Act, a health plan must select all providers who meet the plan's credentialing criteria