AHM-250

AHM-250 practice questions, page 14 of 15, with answer review and explanations.

Question 66

Health plans may use different capitation arrangements for different levels of service. One typical capitation arrangement provides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary services. This type of capitation arrangement is known as a:

  1. global capitation arrangement
  2. gatekeeper arrangement
  3. carve-out arrangement
  4. partial capitation arrangement

Question 67

Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example:

  1. Encounter reports
  2. Diagnostic codes
  3. Durational ratings
  4. Edits

Question 68

Health plans require utilization review for all services administered by its participating physicians.

  1. True
  2. False

Question 69

Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. For health plan partners what is required?

  1. Low or stable costs.
  2. Appropriate, rather than inappropriate, utilization rates.
  3. A benefit that cannot be easily defined.
  4. Defined patient population.

Question 70

Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is that

  1. users can access the Internet using a number of different types of computer systems
  2. access to the Internet is available only to members of the health plan's network
  3. the Internet is immune to internal security breaches by employees or trading partners within the network
  4. users can contact a single controlling organization to rectify disruptions in Internet service