AHM-530

Review 202 AHM-530 practice questions with answer explanations and community insights.

Question 1

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as:

  1. Network management
  2. Quality
  3. Cost-effectiveness
  4. Accessibility

Question 2

Decide whether the following statement is true or false: The organizational structure of a health plan's network management function often depends on the size and geographic scope of the health plan. With respect to the size of a health plan, it is correct to say that smaller health plans typically have less integration and more specialization of roles than do larger health plans.

  1. True
  2. False

Question 3

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. One important activity within the scope of network management is ensuring the quality of the health plan's provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan's pre-established criteria for participation in the network.

  1. authorization
  2. provider relations
  3. credentialing
  4. utilization management

Question 4

One important aspect of network management is profiling, or provider profiling. Profiling is most often used to:

  1. measure the overall performance of providers who are already participants in the network
  2. assess a provider's overall satisfaction with a plan's service protocols and other operational areas
  3. verify a prospective provider's professional licenses, certifications, and training
  4. familiarize a provider with a plan's procedures for authorizations and referrals

Question 5

Network managers rely on a health plan's claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan's claims administration department enables the health plan to:

  1. determine the number of healthcare services delivered to plan members
  2. monitor the types of services provided by the health plan's entire provider network
  3. evaluate providers' practice patterns and compliance with the health plan's procedures for the delivery of care
  4. all of the above
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