AHM-250 Online Practice Questions and Answers

Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that

A. Mr. Marak has the right to appeal to the next level if the Level One appeal upholds the original decision

B. It requires Frazier and Mr. Marak to submit to arbitration in order to resolve the dispute

C. It is considered to be an informal appeal

D. It will be handled by an independent review organization (IRO)

Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special

A. an integrated delivery system (IDS)

B. a Management Services Organization (MSO)

C. a Physician Practice Management (PPM) company

D. a physician-hospital organization (PHO)

Some providers use electronic medical records (EMRs) to document their patients' care in an electronic form. The following statement(s) can correctly be made about EMRs:

A. EMRs are computerized records of a patient's clinical, demographic, and administrator

B. B only

C. Both A and B

D. Neither A nor B

E. A only

In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that

A. hospitals participating in TRICARE program are exempt from JCAHO accreditation and Medicare certification

B. TRICARE enrollees are not entitled to appeal authorization coverage decisions

C. active duty personnel are automatically considered enrolled in TRICARE Prime

D. TRICARE covers inpatient and outpatient services, physician and hospital charges, and medical supplies, but not mental health services

Which of the following statements about EPO and HMO models is FALSE?

A. In-network visit is allowed only on PCP's referral in HMO model.

B. Out-of-network visit is not allowed in HMO model.

C. Out-of-network visit is not allowed in EPO model.

D. In-network visit is allowed only on PCP's referral in EPO model.

In order to measure the expenses of institutional utilization, Holt Health care group uses standard formula to calculate hospital bed stays per 1000 plan members. On 26 November, Holt uses the following information to:

Calculate the bed days per 1000 members for the MTD Total gross hospital bed days in MTD = 500 Plan membership = 15000 Calculate Holt's number of bed days per 1000 members for the month to date, rounded to the nearest

whole number.

A. 468

B. 365

C. 920

D. 500

Flexible Spending Accounts (FSAs) can be established by

A. The employer alone

B. The employee alone

C. By both the employer and the employee

D. Self - employed individuals

In Order to act as a TPA an organization must

A. Establish written procedures for adverse determinations and appeals

B. Obtain a certificate of authority from the state insurance department

C. Designating the organization as a TPA

D. All of the above

The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored

A. anti selection

B. cost shifting

C. receivership

D. underwriting

The Polestar Company's sole business is the ownership of Polaris Medical Group, a health plan and subsidiary of Polestar. Some members of Polestar's board of directors hold positions with Polestar in addition to their positions on the board; the rest are

A. Polestar's relationship to Polaris: partnership Type of board member: operations director

B. Polestar's relationship to Polaris: partnership Type of board member: outside director

C. Polestar's relationship to Polaris: holding company Type of board member: operations director

D. Polestar's relationship to Polaris: holding company Type of board member: outside director