AHIP AHM-250 PAHM Exam Questions Instant Access

Question 1

The following statements are about standards set forth in the Quality Improvement System for Managed Care (QISMC), established by the Health Care Financing Administration (HCFA, now known as the Centers for Medicare and Medicaid Services).

AAs a result of the Balanced Budget Refinement Act (BBRA), PPOs are required to meet all QISMC quality requirements.

BQISMC standards typically do not apply to such Medicare services as mental health or substance abuse services.

CMedicaid primary care case manager (PCCM) programs are subject to the same QISMC quality standards and performance measures as are all other Medicare and Medicaid programs.

DQISMC standards and guidelines are required for Medicare MCOs, but they are applicable to Medicaid MCOs at the discretion of the individual states.

Answer : D

Question 2

If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info

AA Level One appeal, and the member has the right to a further appeal

BA Level Two appeal, and the reviewer's decision is final and binding

CAn independent external appeal, and the member has the right to a further appeal

DArbitration, and the reviewer's decision is final and binding

Answer : A

Question 3

Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr. Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to see

ADr. High serves as the coordinator of care for the medical services that Mr. Canton receives.

BOmega's network of providers includes Dr. High, but not Dr. Miller.

COmega's system allows its members open access to all of Omega's participating providers.

DOmega used a financing arrangement known as a relative value scale (RVS) to compensate Dr. Miller.

Answer : A

Question 4

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice containing the two terms that you have chosen. For providers, (operational /

Aoperational / an acquisition

Boperational / a consolidation

Cstructural / an acquisition

Dstructural / a consolidation

Answer : D

Question 5

Arthur Moyer is covered under his employer's group health plan, which must comply with the Consolidated Omnibus Budget Reconciliation Act (COBRA). Mr. Moyer is terminating his employment. He has elected to continue his coverage under his employer's group

A18 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.

B18 months, even if he obtains group health coverage through another employer.

C36 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.

D36 months, even if he obtains group health coverage through another employer.

Answer : A

Question 6

One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include

Athat it may be a single-specialty or multi-specialty practice

Boperates in one or a few facilities rather than in many independent offices

Cachieves economies of scale in the group's integrated operations

Dall of the above

Answer : D

Question 7

Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a

ACan exclude coverage for treatment of Mr. Gilbert's angina for one year, because HIPAA does not impact a group health plan's pre-existing condition provision.

BCan exclude coverage for treatment of Mr. Gilbert's angina for one year, because Mr. Gilbert did not have at least 36 months of creditable coverage under his previous health plan.

CCan exclude coverage for treatment of Mr. Gilbert's angina for three months, because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan.

DCannot exclude his angina as a pre-existing condition, because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under his previous health plan.

Answer : D

AHIP Healthcare Management: An Introduction AHM-250 PAHM Exam Questions