All About Precise AHM-540 Actual Exam

NEW QUESTION 1
Most health plans require a PCP referral or precertification for CAM benefits.

• A. True
• B. False

Answer: B

NEW QUESTION 2
Drugs included in a health plan’s formulary can be classified according to how freely they can be prescribed. By definition, a drug that requires some sort of review or approval by a plan physician or group of physicians before the prescription can be filled is

• A. an unrestricted drug
• B. a monitored drug
• C. a restricted drug
• D. a conditional drug

Answer: B

NEW QUESTION 3
Determine whether the following statement is true or false: Participation in disease management programs is currently voluntary.

• A. True
• B. False

Answer: A

NEW QUESTION 4
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

• A. standard medical-surgical services
• B. mental health and substance abuse services
• C. services offered to Medicare enrollees as optional supplementary benefits
• D. all of the above

Answer: D

NEW QUESTION 5
This agency oversees fraud and abuse matters as they relate to medical management.

• A. Health Resources and Services Administration (HRSA)
• B. Office of Personnel Management (OPM)
• C. Department of Health and Human Services (HHS)
• D. Department of Justice (DOJ)

Answer: D

NEW QUESTION 6
Three general categories of coverage policy—medical policy, benefits administration policy, and administrative policy—are used in conjunction with purchaser contracts to determine a health plan’s coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan’s

• A. medical policy evaluates clinical services against specific benefits language rather than against scientific evidence
• B. benefits administration policy determines whether a particular service is experimental or investigational
• C. benefits administration policy focuses on both clinical and nonclinical coverage issues
• D. administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes

Answer: D

NEW QUESTION 7
Determine whether the following statement is true or false:
Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.

• A. True
• B. False

Answer: A

NEW QUESTION 8
To improve members’ abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.

• A. The primary role of telephone triage clinical staff is to diagnose the caller’s condition and give medical advice.
• B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.
• C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.
• D. A telephone triage program may also include a self-care component.

Answer: B

NEW QUESTION 9
Outcomes management is a tool that health plans use to maximize all the results
associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:
* 1. The goal of outcomes management is to identify and implement treatments that are cost- effective and deliver the greatest value
* 2. Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: A

NEW QUESTION 10
Determine whether the following statement is true or false:
The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

• A. True
• B. False

Answer: B

NEW QUESTION 11
As a follow-up to a performance improvement plan for member services, the Stellar Health Plan conducted an evaluation of the success of the plan. Stellar conducted its evaluation as the plan was being carried out. The evaluation focused on specific activities and assessed the relative importance of those activities to the plan as a whole. This information indicates that Stellar’s evaluation of the plan was both

• A. concurrent and formative
• B. concurrent and summative
• C. retrospective and formative
• D. retrospective and summative

Answer: A

NEW QUESTION 12
The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as

• A. generic substitution, and prescriber approval is not required
• B. generic substitution, and prescriber approval is always required
• C. therapeutic substitution, and prescriber approval is not required
• D. therapeutic substitution, and prescriber approval is always required

Answer: D

NEW QUESTION 13
Designing effective medical management programs for Medicare beneficiaries requires an understanding of the unique health needs of the Medicare population. One characteristic of Medicare beneficiaries is that they typically

• A. do not experience mental health problems
• B. consume more than half of all prescription drugs
• C. are likely to equate quality with the technical aspects of clinical procedures
• D. require longer and more costly recovery periods following acute illnesses or injuries than does the general population

Answer: D

NEW QUESTION 14
Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman’s condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation care unit. Transferring Ms. Newman to the observation care unit most likely

• A. resulted in unnecessarily expensive charges for treatment
• B. prevented M
• C. Newman from receiving immediate attention for her condition
• D. gave M
• E. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region
• F. allowed clinical staff an opportunity to determine whether M
• G. Newman required hospitalization without actually admitting her

Answer: D

NEW QUESTION 15
Determine whether the following statement is true or false:
Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.

• A. True
• B. False

Answer: B

NEW QUESTION 16
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
The following statement(s) can correctly be made about Harbrace’s use of extra- contractual coverage:
* 1. Harbrace’s medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray
* 2. One way for Harbrace to reduce the risk associated with extra-contractual coverage is by including an alternative care provision in its contracts with purchasers

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: C

NEW QUESTION 17
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