AHM-250

AHM-250 practice questions, page 4 of 15, with answer review and explanations.

Question 16

Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo some type of external review process. This process:

  1. Is voluntary for health plans.
  2. Requires all change accreditation organizations to use the same standards of accreditation.
  3. Typically requires the accrediting organization to conduct a medical record review and a review of a health plan's credentialing processes, but not an evaluation of the health plans' member service systems processes.
  4. Cannot assure that a health plan meets a specified level of quality.

Question 17

Amendments to the HMO act 1973 do not permit federally qualified HMO’s to use

  1. Retrospective experience rating
  2. Adjusted community rating
  3. Community rating by class
  4. Community rating

Question 18

An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO

  1. Is regulated under federal HMO legislation
  2. Generally provides no benefits for out-of-network care
  3. Has no provider network of physicians
  4. Is not subject to state insurance laws

Question 19

An HMO that combines characteristics of two or more HMO models is sometimes referred to as a

  1. Network model HMO
  2. Group model HMO
  3. Staff model HMO
  4. Mixed model HMO

Question 20

Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:

  1. Codes
  2. Lists
  3. Edits
  4. Checks