AHM-530 Exam Dumps - AHIP Certification Questions and Answers

Utilization management committee

Peer review committee

Medical advisory committee

Credentialing committee

They are available to United States citizens only after they reach age 65.

They have an upper dollar limit.

They receive a monthly capitation that is set at 100% of the Adjusted Average Per Capita Cost (AAPCC).

PACE providers receive capitated payments only through the PACE agreement.

The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.

States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.

Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.

A per diem system typically places a healthcare facility at risk for controlling utilization and costs internally.

One likely reason that an health plan would use a fee schedule system to compensate providers is that this system transfers most of the financial risk to the provider.

Under a salary system, a provider assumes no service risk.

The use of a FFS or a salary system allows an health plan to transfer a greater proportion of financial risk to providers than does the use of capitation.

Risk pools based on aggregate provider performance eliminate problems associated with “free riders.”

A hospital bonus pool is usually split between the health plan and the PCPs.

Bonus pools based on the performance of specific providers are usually easier to administer than those based on the performance of the plan as a whole.

For providers, withhold arrangements eliminate the risk of losing base income.

Disease-specific arrangement

Contact capitation arrangement

Risk adjustment arrangement

Withhold arrangement

provisions for marketing the plan’s product

payment arrangements between the plan and the provider

verification of the plan’s eligibility to do business

management of the contents of members’ medical records

An MRK covers the content of specific patient records of a provider.

The NCQA requires an examination of MRK with all of a health plan's office evaluations.

An MRR includes a review of the policies, procedures, and documentation standards the provider follows to create and maintain medical records.

The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's network.

Due process standard

Subrogation standard

Corrective action standard

Prudent layperson standard

Two measures of BH quality are patient satisfaction and clinical outcomes assessments.

For a health plan, one argument in favor of contracting with a managed behavioral healthcare organization (MBHO) is that the health plan's members can gain faster access to BH care.

In their contracts with health plans, managed behavioral healthcare organizations (MBHOs) usually receive delegated authority for network development and management.

Health plans generally compensate managed behavioral healthcare organizations (MBHOs) on an FFS basis.