Exam 1: AHM Medical Management

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

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. Greenhouses prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

A health plans 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 plans 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

Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

Among this agencys accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either shall standards or should standards.

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).

Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

The Strathmore Health Plan uses clinical pathways to manage its acute care services. In order to reduce the risk of financial liability associated with the use of clinical pathways, Strathmore and its network hospitals should

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.

Occasionally, employers combine workers' compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24- hour coverage is that it typically

Determine whether the following statement is true or false: The delegation of medical management functions to providers can occur without the transfer of financial risk.

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

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 delegators accrediting agency