AHIP AHM-540 - Medical Management Exam

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Total 163 questions

PBMs are accredited by the same organizations that accredit health plans.

  • A. True
  • B. False


Answer : B

The Westchester Health Plan classifies its key processes into the following categories: high-risk, high-volume, problem-prone, and high-cost. Westchester also prioritizes the categories in terms of importance. The process category that Westchester most likely ranks highest in importance is

  • A. High-risk processes
  • B. High-volume processes
  • C. Problem-prone processes
  • D. High-cost processes


Answer : A

With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT

  • A. maintaining clinical practices
  • B. delivering performance feedback to providers
  • C. participating in utilization management (UM) activities
  • D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management


Answer : A

Federal laws, such as the Employee Retirement Income Security Act (ERISA), the
Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and
Accountability Act (HIPAA), have affected medical management activities by health plans.
Consider the following provisions of federal regulations:
Provision 1Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and
Provision 2, respectively.

  • A. Provision 1- ERISA Provision 2- HIPAA
  • B. Provision 1- HIPAA Provision 2- ERISA
  • C. Provision 1- BBA of 1997 Provision 2- HIPAA
  • D. Provision 1- ERISA Provision 2- BBA of 1997


Answer : A

For this question, if answer choices (A) through (C) are all correct, select answer choice
(D). Otherwise, select the one correct answer choice.
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say

  • A. that the construction of a data warehouse is quick and simple
  • B. that a data warehouse addresses the problems associated with multiple data management systems
  • C. that a data warehouse stores only current data
  • D. all of the above


Answer : B

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Total 163 questions