NEW QUESTION 1
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 2
One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. A HIN may afford a health plan better measurements of outcomes and provider performance.
• B. The use of a HIN typically increases a health plan’s exposure to liability for poor care.
• C. Most HINs are Internet-based rather than built on proprietary computer networks.
• D. Currently, the majority of health plans do not have HINs that are capable of transferring medical records among their network providers.

Answer: B

NEW QUESTION 3
The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid Services (CMS) requires compliance with QAPI from

• A. both Medicare+Choice plans and Medicaid health plans
• B. Medicare+Choice plans only
• C. Medicaid health plans only
• D. neither Medicare+Choice plans nor Medicaid health plans

Answer: B

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.
Ways that workers’ compensation health plans can help control the costs of job-related injuries and illnesses include

• A. applying strict definitions of medical necessity
• B. developing prevention and recovery programs
• C. applying out-of-network benefit reductions
• D. all of the above

Answer: B

NEW QUESTION 5
Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.
The following statements are about accreditation. Select the answer choice containing the correct statement.

• A. At the request of health plans, accrediting agencies gather the data needed for accreditation.
• B. Most purchasers and consumers review accreditation results when making decisions to purchase or enroll in a specific health plan.
• C. Accreditation is typically conducted by independent, not-for-profit organizations.
• D. All health plans are required to participate in the accreditation process.

Answer: C

NEW QUESTION 6
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 two terms or phrases that you have selected.
The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

• A. objective / degree
• B. objective / cause
• C. both objective and subjective / degree
• D. both objective and subjective / cause

Answer: A

NEW QUESTION 7
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 8
Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

• A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation
• B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions
• C. cover only services delivered in an acute inpatient setting
• D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

Answer: B

NEW QUESTION 9
Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by

• A. severing the link between Medicaid and public assistance
• B. eliminating the need for applications for Medicaid and public assistance
• C. allowing states to provide healthcare benefits to groups outside the traditional Medicaid population
• D. providing supplemental funding for dual eligibles in the form of five-year block grants

Answer: A

NEW QUESTION 10
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 1—Limits 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 2—Establishes 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

NEW QUESTION 11
The following statement(s) can correctly be made about the scope of case management:
* 1. Case management incorporates activities that may fall outside a health plan’s typical responsibilities, such as assessing a member’s financial situation
* 2. Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review
* 3. Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs

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

Answer: D

NEW QUESTION 12
For this question, if answer choices (1) through (3) are all correct, select answer choice (4). Otherwise, select the one correct answer choice.
Health plans sometimes delegate selected medical management activities to their providers or other external entities. Activities that are frequently delegated include

• A. utilization review (UR)
• B. quality management (QM)
• C. preventive health services
• D. all of the above

Answer: A

NEW QUESTION 13
The Noble Health Plan conducted a cost/benefit analysis of the following four prescription drugs:
BenefitCost Drug A$525$350 Drug B$450$250
Drug C$400$200 Drug D$350$100
According to this analysis, the drug that represents the most efficient use of resources is

• A. Drug A
• B. Drug B
• C. Drug C
• D. Drug D

Answer: D

NEW QUESTION 14
The following statements are about health plans’ development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests.
• B. Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not.
• C. The medical policy development process includes both a clinical and an operational review of a proposed medical policy.
• D. The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.

Answer: A

NEW QUESTION 15
The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton’s prospective UR activities are likely to include

• A. documenting the clinical details of the patient’s condition and care
• B. tracking the length of inpatient stay
• C. completing the discharge planning process
• D. determining the most appropriate setting for the proposed course of care

Answer: D

NEW QUESTION 16
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. _________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.

• A. A clinical practice guideline (CPG)
• B. Medical policy
• C. Benefits administration policy
• D. A standard of care

Answer: B

NEW QUESTION 17
To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

• A. based on Web-based technologies
• B. available only to the employees of the health plan
• C. publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems
• D. used to handle the majority of health plan eCommerce

Answer: A

NEW QUESTION 18
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

NEW QUESTION 19
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