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NEW QUESTION 1
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 2
The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.
Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

  • A. activities of daily living / functional status
  • B. activities of daily living / health status
  • C. instrumental activities of daily living / functional status
  • D. instrumental activities of daily living / health status

Answer: A

NEW QUESTION 3
The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

  • A. One advantage of EDI over manual data management systems is improved data integrity.
  • B. EDI may use the Internet as the communication link between the participating parties.
  • C. EDI involves back-and-forth exchanges of information concerning individual transactions.
  • D. The data format for EDI is agreed upon by the sending and receiving parties.

Answer: C

NEW QUESTION 4
Administrative action plans are used when performance problems or opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:
* 1.Administrative action plans allow health plans to coordinate management activities
* 2.One function of administrative action plans is to integrate service across all levels of the organization
* 3.Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health

  • A. All of the above
  • B. 1 and 2 only
  • C. 1 and 3 only
  • D. 2 and 3 only

Answer: B

NEW QUESTION 5
Health plans often use accreditation as a means of evaluating the quality of care delivered to plan members. Accreditation of subacute care providers is available from the

  • A. National Committee for Quality Assurance (NCQA)
  • B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • C. American Accreditation HealthCare Commission/URAC (URAC)
  • D. Foundation for Accountability (FACCT)

Answer: B

NEW QUESTION 6
Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

  • A. effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan
  • B. effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy
  • C. the effectiveness of an action plan is typically measured with a concurrent evaluation
  • D. an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions

Answer: B

NEW QUESTION 7
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 8
In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

  • A. achievable within a specified timeframe
  • B. defined in terms of multiple results
  • C. expressed in subjective, qualitative terms
  • D. all of the above

Answer: A

NEW QUESTION 9
Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

  • A. Health plans rarely delegate HRA activities to external entities
  • B. Health plans typically focus their HRA efforts on newly enrolled members
  • C. HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members
  • D. HRA is generally a reliable predictor of medical resource utilization

Answer: B

NEW QUESTION 10
The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to

  • A. remove behavioral healthcare services from the primary care setting
  • B. shift behavioral healthcare from acute inpatient settings to alternative settings when feasible
  • C. reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient
  • D. offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members

Answer: B

NEW QUESTION 11
The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self- care most likely would not be appropriate.

  • A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.
  • B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.
  • C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.
  • D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

Answer: A

NEW QUESTION 12
Determine whether the following statement is true or false:
The utilization review (UR) process produces the greatest number of case management referrals.

  • A. True
  • B. False

Answer: A

NEW QUESTION 13
The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
* 1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
* 2.The National Committee for Quality Assurance (NCQA)
* 3.The American Accreditation HealthCare Commission/URAC (URAC)

  • A. All of the above
  • B. 1 and 2 only
  • C. 2 and 3 only
  • D. 1 only

Answer: B

NEW QUESTION 14
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
One component of UR is an administrative review. An administrative review compares the proposed medical care to the applicable (medical policy / contract provision). This type of review (can / cannot) be conducted by a nonclinical staff member.

  • A. medical policy / can
  • B. medical policy / cannot
  • C. contract provision / can
  • D. contract provision / cannot

Answer: C

NEW QUESTION 15
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 16
A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
* 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence
* 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
* 3. All of the criteria for coverage decisions must be included in the purchaser contract

  • A. All of the above
  • B. 1 and 2 only
  • C. 2 only
  • D. 3 only

Answer: B

NEW QUESTION 17
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 18
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