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AHM-250Q&As
Healthcare Management: An Introduction
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QUESTION 1
Col. Martin Avery, on active duty in the U.S. Army, iseligibleto receive healthcare benefits under one of the three
TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be
A. able to obtain full benefits for services obtained from network and non-network providers
B. subject to copayment, deductible, and coinsurance requirements for any medical care he receives
C. required to formally enroll for coverage and pay an enrollment fee
D. assigned to a primary care manager who is responsible for coordinating all his care
Correct Answer: D
QUESTION 2
According to the IRS, which of the following is not an allowable preventive care service?
A. Smoking cessation programs.
B. Periodic health examinations.
C. Health club memberships.
D. Immunizations for children and adults.
Correct Answer: C
QUESTION 3
The nature of the claims function within health plans varies by type of plan and by the compensation arrangement that
the plan has made with its providers. For example, it is generally correct to say that, in a Preferred provider organization
(PPO)
A. Both A and B
B. A only
C. B only
D. Neither A nor B
Correct Answer: A
QUESTION 4

Some states mandate that an independent enrollment broker or benefits counselor contractor selected by the state must
manage enrollment of the eligible Medicaid population into managed care. In other states a health plan can engage
independent brokers and
A. Many states have regulations that prohibit health plans from using door-to-door and/or telephone solicitation to
market health plan products to the Medicaid population.
B. Health plans are never allowed to medically underwrite individual market customers who are under age 65.
C. To promote a health plan product to the individual market, health plans typically use captive agents who give sales
presentations to potential customers, rather than using promotion tools such as direct mail, telemarketing, or
advertising.
D. Health plans typically are allowed to medically underwrite all individual market customers who are covered by
Medicare and can refuse to cover such customers.
Correct Answer: A
QUESTION 5
The statements below describe technology used by two health plans to respond to incoming telephone calls:
The Manor Health Plan uses an automated system that answers telephone calls with recorded or synthesized speech
and prompts the caller to respond t
A. Manor\\'s system is best described as an automated call distributor (ACD).
B. Both Manor\\'s system and Squire\\'s device are applications of computer/telephone integration (CTI).
C. Squire\\'s device is best described as an interactive voice response (IVR) system.
D. All of these statements are correct.
Correct Answer: B
QUESTION 6
The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its
treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle,
Oriole pays Islet
A. an amount based on the weighted value of each medical procedure or service that Isle provides, and the weighted
value is determined by the appropriate current procedural terminology (CPT) code for the procedure or service
B. a fixed rate based on average expected use of hospital resources in a given geographical area for that DRG
C. a retrospective reimbursement based on the actual costs of the Oriole member\\'s hospitalization
D. a specific negotiated amount for each day the Oriole member is hospitalized
Correct Answer: B

QUESTION 7
When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO),
the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had
been covered under a previous
A. 230
B. 270
C. 220
D. 180
Correct Answer: C
QUESTION 8
The Helm MCO segmented the non-group market for its new healthcare product by using factors such as education
level, gender, and household composition. The Amberly MCO segmented the non-group market for its products based
on the approaches by which it solution
A. demographic product or benefit
B. geographic distribution channel
C. demographic distribution channel
D. geographic product or benefit
Correct Answer: C
QUESTION 9
Specialty services with certain characteristics tend to make good candidates for health plan approaches. One
characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the
service should have
A. a defined patient population
B. a complex benefit structure
C. low, stable costs
D. appropriate utilization rates
Correct Answer: A

QUESTION 10
The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of
the group practice, have an equity interest in the practice, and provide
A. A captive group a staff model
B. A captive group a network model
C. An independent group a network model
D. An independent group a staff model
Correct Answer: B
QUESTION 11
From the following answer choices, choose the description of the ethical principle that best corresponds to the term
Autonomy
A. Health plans and their providers are obligated not to harm their members
B. Health plans and their providers should treat each member in a manner that respects the member\\'s goals and
values, and they also have a duty to promote the good of the members as a group
C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among
the members
D. Health plans and their providers have a duty to respect the right of their members to make decisions about the
course of their lives
Correct Answer: D
QUESTION 12
Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results
in higher reimbursement to the provider is called ______________.
A. Coding error
B. Overcharging
C. Upcoming
D. Unbundling
Correct Answer: C
QUESTION 13

The main purpose of the Health Plan Employer Data and Information Set (HEDIS) is to provide
A. expert consultation to end-users for solving specialized and complex healthcare problems through the use of a
knowledge-based computer system
B. a comprehensive accreditation for PPOs
C. measurements of plan performance and effectiveness that potential healthcare purchasers can use to compare
quality offered by different healthcare plans
D. a mathematical model that can predict future claim payments and premiums
Correct Answer: C
QUESTION 14
One way in which a health plan can support an ethical environment is by
A. requiring organizations with which it contracts to adopt the plan\\'s formal ethical policy
B. developing and maintaining a culture where ethical considerations are integrated into decision making at the top
organizational level only
C. establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultant
D. maintaining control of policy development by removing providers and members from the process of developing and
implementing policies and procedures that provide guidance to providers and members confronted with ethical issues
Correct Answer: C
QUESTION 15
The Mosaic health plan uses a typical electronic medical record (EMR) to document the medical care its members
receive. One characteristic of Mosaic\\'s EMR is that it:
A. Does not provide any clinical decision support for Mosaic\\'s providers.
B. Is designed to supply information at the site of care.
C. Contains a Mosaic member\\'s clinical data only.
D. Is organized by the type of treatment or by provider.
Correct Answer: B
QUESTION 16
From the answer choices below, select the response that correctly identifies the rating method that Mr. Sybex used and
the premium rate PMPM that Mr. Sybex calculated for the Koster group.
A. Rating Method book rating Premium Rate PMPM $132

B. Rating Method book rating Premium Rate PMPM $138
C. Rating Method blended rating Premium Rate PMPM $132
D. Rating Method blended rating Premium Rate PMPM $138
Correct Answer: C
QUESTION 17
High deductible health plans (HDHP) are characterized by all of the following features except
A. A HDHPs have a higher deductible than other traditional insurance products such as HMOs and PPOs.
B. HDHPs generally cost more than traditional heathcare coverage.
C. Some HDHPs cover preventive care on a first-dollar coverage basis.
D. All of the above
Correct Answer: A
QUESTION 18
A differences between managed indemnity and traditional indemnity
A. Include precertification and utilization review techniques
B. Both are the same
C. Include network and quality review techniques
D. A and B
Correct Answer: C
QUESTION 19
In addition to the credentialing activities that an health plan performs when initially accepting a provider into its network,
the health plan must also perform recredentialing of the same providers on an ongoing basis. Many of the same
activities are per
A. verification of a network provider\\'s medical education and residency
B. performance of site inspections in a provider\\'s facilities
C. review of information from a provider\\'s quality improvement activities
D. verification of a provider\\'s licensure and certification
Correct Answer: A

QUESTION 20
Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed
care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of
benefits provision
A. 380
B. 130
C. 0
D. 550
Correct Answer: A
QUESTION 21
In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of
anti selection. Anti selection can correctly be defined as the
A. inability of a proposed insured to share with the insurer the financial risks of healthcare coverage
B. possibility that a proposed insured will profit from an illness by receiving benefits that exceed the total amount of his
or her eligible medical expenses
C. inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable risk
D. tendency of people who have a greater-than-average likelihood of loss to apply for or continue insurance protection
to a greater extent than people who have an average or less than average likelihood of the same loss
Correct Answer: D
QUESTION 22
Phillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is
his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication
of benefits price
A. $0
B. $300
C. $400
D. $900
Correct Answer: C

QUESTION 23
Integration of provider organizations is said to occur when
A. Previously separate providers combine and come under common ownership or control.
B. Two or more providers combine their business operations that they previously carried out separately.
C. Both A and B
D. None of the above
Correct Answer: C
QUESTION 24
To achieve widespread use of electronic data interchange (EDI) in the healthcare industry, all entities within the industry
need to agree on industry standards regarding the information format and software to be used. Several organizations
are making cont
A. Computer-based Patient Records Institute (CPRI)
B. American National Standards Institute (ANSI)
C. American Health Information Management Association (AHIMA)
D. American Medical Association (AMA)
Correct Answer: B
QUESTION 25
Natalie Chan is a member of the Ultra Health Plan, a health plan. Whenever she needs nonemergency medical care,
she sees Dr. David Craig, an internist. Ms. Chan cannot self- refer to a specialist, so she saw Dr. Craig when she
experienced headaches. Dr. Cr
A. Within Ultra\\'s system, Ms. Chan received primary care from both Dr. Craig and Dr. Lee
B. Ultra\\'s system allows its members open access to all of Ultra\\'s participating providers.
C. Within Ultra\\'s system, Dr. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms.
Chan receives.
D. Ultra\\'s network of providers includes Dr. Craig and Dr. Lee but not Arrow Hospital
Correct Answer: C
QUESTION 26

One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers\\' payment during a
plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for
referral or hospital
A. withholds
B. usual, customary, and reasonable (UCR) fees
C. risk pools
D. per diems
Correct Answer: A
QUESTION 27
To determine fee reimbursements to be paid to physicians, the Triangle Health Plan assigns a weighted value to each
medical procedure or service and multiplies the weighted value by a money multiplier. Triangle and the providers
negotiate the value of the
A. diagnosis-related group (DRG) system
B. relative value scale (RVS)
C. partial capitation arrangement
D. capped fee system
Correct Answer: B
QUESTION 28
Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized
for chest pains, and she incurred charges for:
The cost of hospitalization for two days Diagnostic tests performed in the hospital Trans
A. ambulance and the diagnostic tests
B. ambulance, the diagnostic tests, and the physician\\'s professional services
C. cost of hospitalization
D. cost of hospitalization and the physician\\'s professional services
Correct Answer: D
QUESTION 29
To determine fee reimbursements to be paid to physicians, the Triangle Health Plan assigns a weighted value to each
medical procedure or service and multiplies the weighted value by a money multiplier. Triangle and the providers

negotiate the value of the
A. Diagnosis-related group (DRG) system
B. Relative value scale (RVS)
C. Partial capitation arrangement
D. Capped fee system
Correct Answer: B
QUESTION 30
Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area.
Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a
PCP in Green
A. Greentree is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is complete
B. any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing
process within a defined time frame in order for the contract to be effective
C. Greentree must offer a standard contract to Dr. Cortelyou, without regard to the outcome of the credentialing process
D. Greentree will abandon the credentialing process now that Dr. Cortelyou has agreed to participate in Greentree\\'s
network
Correct Answer: B
QUESTION 31
In health plan terminology, demand management, as used by health plans, can best be described as
A. an evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans
for a given patient
B. a series of strategies designed to reduce plan members\\' needs to utilize healthcare services by encouraging
preventive care, wellness, member self-care, and appropriate use of healthcare services
C. a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan
member for any fees that exceed the maximum fee reimbursed by the plan
D. a system of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those
needs, and coordinating and monitoring the care
Correct Answer: B
QUESTION 32
Keith Murray is a 45 year old chartered accountant and is employed in Livingstone consultancy firm. He has been
paying payroll taxes for the past 15 years. Which of the following statements is true regarding Medicare Part A

entitlement?
A. Keith shall be entitled to Part A benefits when he attains 65 years of age
B. Keith\\'s wife shall be entitled to Part A benefits when she attains 65 years of age
C. Keith\\'s wife shall be required to pay a monthly premium in order to receive Medicare Part A benefits
D. Both a and b
Correct Answer: D
QUESTION 33
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
Correct Answer: A
QUESTION 34
Lansdale Healthcare, a health plan, offers comprehensive healthcare coverage to its members through a network of
physicians, hospitals, and other service providers. Plan members who use in-network services pay a copayment for
these services. The copayment
A. specified dollar amount charge that a plan member must pay out-of-pocket for a specified medical service at the time
the service is rendered
B. percentage of the fees for medical services that a plan member must pay after Magellan has paid its share of the
costs of those services
C. flat amount that a plan member must pay each year before Magellan will make any benefit payments on behalf of the
plan member
D. specified payment for services that was negotiated between the provider and Magellan
Correct Answer: A
QUESTION 35
The following statements are about accreditation in health plans. Select the answer choice that contains the correct
statement.
A. Accreditation is typically performed by a panel of physicians and administrators employed by the health plan under

evaluation.
B. All accrediting organizations use the same standards of accreditation.
C. Results of accreditation evaluations are provided only to state regulatory agencies and are not made available to the
general public.
D. Accreditation demonstrates to an health plan\\'s external customers that the plan meets established standards for
quality care.
Correct Answer: D
QUESTION 36
Which of the following factors have contributed to the limited popularity of FSAs
A. "Use it or lose it" provision
B. Lack of portability
C. Only self-employed individuals are eligible for establishing FSAs.
D. Both A andB
Correct Answer: D
QUESTION 37
Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member
of a health plan that will allow him to select the physician of his choice, either from within his plan\\'s network or from
outside of h
A. a traditional HMO plan
B. a managed indemnity plan
C. a point of service (POS) option
D. an exclusive provider organization (EPO)
Correct Answer: C
QUESTION 38
The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true
statement about these types of reviews is that:
A. An administrative review must be conducted by a health plan staff member who is a medical professional.
B. The primary purpose of an administrative review is to evaluate the appropriateness of a proposed medical service.

C. UR staff members typically conduct a medical review of a proposed medical service before they conduct an
administrative review for that same service.
D. One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.
Correct Answer: D
QUESTION 39
What are the characteristics that the underwriter has to consider while determining the premium rate for health
insurance coverage for a group?
A. Level of benefits
B. Geographic location
C. Group size
D. All the above
Correct Answer: D
QUESTION 40
The following statements describe healthcare services delivered to health plan members by plan providers. Select the
statement that describes a service that would most likely require utilization review and authorization.
A. Adele Farnsworth visited a dermatologist to have a mole removed from her arm.
B. Jonathan Lang underwent an electrocardiogram (EKG) during an office visit with his cardiologist.
C. Corinne Maxwell underwent physical therapy after being hospitalized for hip replacement surgery.
D. Jose Redriguez, a 70-year-old Medicare patient, received a flu shot as part of his annual physical examination.
Correct Answer: C
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Following Questions and Answers are all new published by AHIP

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 1 / 15

C. required to formally enroll for coverage and pay an enrollment fee

A. Smoking cessation programs.

B. Periodic health examinations.

C. Health club memberships.

D. Immunizations for children and adults.

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 2 / 15

A. Manor\\'s system is best described as an automated call distributor (ACD).

C. Squire\\'s device is best described as an interactive voice response (IVR) system.

D. All of these statements are correct.

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 3 / 15

A. demographic product or benefit

B. geographic distribution channel

C. demographic distribution channel

D. geographic product or benefit

A. a defined patient population

B. a complex benefit structure

C. low, stable costs

D. appropriate utilization rates

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 4 / 15

The following statements describe two types, or models, of HMOs:

A. A captive group a staff model

B. A captive group a network model

C. An independent group a network model

D. An independent group a staff model

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 5 / 15

B. a comprehensive accreditation for PPOs

One way in which a health plan can support an ethical environment is by

B. Is designed to supply information at the site of care.

C. Contains a Mosaic member\\'s clinical data only.

D. Is organized by the type of treatment or by provider.

A. Rating Method book rating Premium Rate PMPM $132

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 6 / 15

B. Rating Method book rating Premium Rate PMPM $138

C. Rating Method blended rating Premium Rate PMPM $132

D. Rating Method blended rating Premium Rate PMPM $138

B. HDHPs generally cost more than traditional heathcare coverage.

C. Some HDHPs cover preventive care on a first-dollar coverage basis.

D. All of the above

A differences between managed indemnity and traditional indemnity

A. Include precertification and utilization review techniques

B. Both are the same

C. Include network and quality review techniques

A. verification of a network provider\\'s medical education and residency

B. performance of site inspections in a provider\\'s facilities

C. review of information from a provider\\'s quality improvement activities

D. verification of a provider\\'s licensure and certification

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 7 / 15

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 8 / 15

Integration of provider organizations is said to occur when

D. None of the above

A. Computer-based Patient Records Institute (CPRI)

B. American National Standards Institute (ANSI)

C. American Health Information Management Association (AHIMA)

D. American Medical Association (AMA)

Latest AHM-250 Dumps | AHM-250 PDF Dumps | AHM-250 Exam Questions 9 / 15

B. usual, customary, and reasonable (UCR) fees

A. diagnosis-related group (DRG) system

B. relative value scale (RVS)

C. partial capitation arrangement