11 January, 2025

Best Quality AHIP AHM-540 Free Question Online

It is impossible to pass AHIP AHM-540 exam without any help in the short term. Come to Examcollection soon and find the most advanced, correct and guaranteed AHIP AHM-540 practice questions. You will get a surprising result by our Abreast of the times Medical Management practice guides.

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Total 163 questions Full Exam Access

Question 1

The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Children with chronic conditions use more physician and nonphysician professional services than do children in the general population.

The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population.

Medicaid-eligible children are at risk for seriousmental and physical conditions.

Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.

Question 2

The following statements are about health plans’ development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests.

Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not.

The medical policy development process includes both a clinical and an operational review of a proposed medical policy.

The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.

Question 3

The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC’s standards and the type(s) of organizations to which these standards may be applied.

Type(s) of Services-on-site services only Type(s) of Organization-health plans only

Type(s) of Services-on-site services only Type(s) of Organization-any organization that performs case management functions

Type(s) of Services-both telephonic and on-site services Type(s) of Organization-health plans only

Type(s) of Services-both telephonic and on-site services Type(s) of Organization-any organization that performs case management functions

Question 4

In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for

evaluating and selecting drugs for inclusion in the formulary

overseeing the manufacture, distribution, and marketing of prescription drugs

certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs

all of the above

Question 5

Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
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 that you have chosen.
Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

open / mandatory

open / voluntary

closed / mandatory

closed / voluntary

Question 6

The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

evaluate all providers without considering differences in risk

focus on specific clinical decisions of Garnet’s providers rather than on patterns of care

identify the outliers and high-value providers in its provider network

measure the effectiveness, but not the efficiency, of Garnet’s providers

Question 7

Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for
* 1. Routine eye care
* 2. Clinical eye care

Both 1 and 2

1 only

2 only

Neither 1 nor 2

Question 8

The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision.

Disease management programs serve to improve both clinical and financial outcomes for healthcare services related to chronic conditions.

Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management.

Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

Question 9

When conducting performance assessment, a health pln may classify the key processes associated with its services into the following categories: high-risk, high-volume, problem- prone, and high-cost.
The following statements are about this classification of processes. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

In some instances, relatively inexpensive processes can qualify as high-cost processes.

Each process must be classified into a single category.

High-risk processes most often involve medical interventions or treatment plans for acute illnesses or case management processes for complex conditions.

Administrative processes such as scheduling appointments are examples of high- volume processes.

Question 10

Emilio Martinez, a member of the Bloom Health Plan, has recently been diagnosed with prostate cancer by his physician, Dr. Robert Cohen. Mr. Martinez has decided to participate in Bloom’s shared decision-making program for prostate cancer. On the basis of this information, it is most likely correct to say
* 1. That verification of Mr. Martinez’s understanding about his care options protects both Dr. Cohen and Bloom against charges of malpractice
* 2. That Mr. Martinez and Dr. Cohen will discuss the care options available to Mr. Martinez, but the ultimate decision about care is up to Dr. Cohen

Both 1 and 2

1 only

2 only

Neither 1 nor 2

Question 11

Acute care refers to healthcare services for medical problems that

are expected to continue for a minimum of 30 days

are typically treated in a provider’s office or outpatient facility

require prompt, intensive treatment by healthcare providers

require low utilization of resources

Question 12

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

utilization management (UM)

quality management (QM)

care management

clinical practice management

Question 13

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

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

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

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

Question 14

When analyzing and applying HRA results, the Multistate Health Plan noted sampling bias. This information indicates that the HRA results

do not accurately depict the characteristics of the Multistate member population under study because of errors in data collection

are more accurate for individual Multistate members than they are for the total population

cannot be stated in numerical terms

indicate variation in the number, types, and severity of behavioral risks presented by Multistate’s members

Question 15

Health plans that offer healthcare programs for Medicare beneficiaries have a strong financial incentive for identifying high-risk seniors as early as possible. The identification of high-risk seniors is typically accomplished through the use of

case management

geriatric evaluation and management (GEM)

intervention identification

interdisciplinary home care (IHC)

Question 16

Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

can measure and report quality only at the provider level

use a single system to deliver services to all plan members

provide an organizational focus for accountability

can use the same performance measures for all products and plans

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Total 163 questions Full Exam Access