NEW QUESTION 1
Maxwell Midler’s health plan operates a drug formulary that includes a typical three-tier copayment structure with required copayments of $5, $10, and $25. Mr. Midler recently filled a prescription for a $75 drug that was not included in the formulary. According to the plan’s formulary copayment structure, the amount that Mr. Midler was required to pay for his prescription was

• A. $5
• B. $10
• C. $25
• D. $75

Answer: C

NEW QUESTION 2
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 3
When conducting performance assessment, a health pln may classify the key processes associated with its services into the following categories: high-risk, high-volume, problem- prone, and high-cost.
The following statements are about this classification of processes. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. In some instances, relatively inexpensive processes can qualify as high-cost processes.
• B. Each process must be classified into a single category.
• C. High-risk processes most often involve medical interventions or treatment plans for acute illnesses or case management processes for complex conditions.
• D. Administrative processes such as scheduling appointments are examples of high- volume processes.

Answer: B

NEW QUESTION 4
Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.
The document that Mr. Farrell is using to communicate his end-of-life healthcare wishes to his family is known as a

• A. medical power of attorney
• B. patient assessment and care plan
• C. living will
• D. healthcare proxy

Answer: C

NEW QUESTION 5
The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

• A. detailing
• B. cognitive services
• C. counter detailing
• D. drug efficacy study implementation (DESI)

Answer: C

NEW QUESTION 6
Health plans that offer healthcare programs for Medicare beneficiaries have a strong financial incentive for identifying high-risk seniors as early as possible. The identification of high-risk seniors is typically accomplished through the use of

• A. case management
• B. geriatric evaluation and management (GEM)
• C. intervention identification
• D. interdisciplinary home care (IHC)

Answer: C

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.
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 8
The following statement(s) can correctly be made about performance measurement systems:
* 1.The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes
* 2.A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

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

Answer: C

NEW QUESTION 9
The following statement(s) can correctly be made about the use of screening for secondary prevention:
* 1. Screening activities may involve specialty care providers as well as primary care providers (PCPs) and the health plan
* 2. Secondary prevention often results in more utilization of services immediately following screening
* 3. Screening focuses on members who have not experienced any symptoms of a particular illness

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

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
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 12
MCOs usually have a formal program for the oversight of delegated activities. The following statements concern typical delegation oversight programs. Select the answer choice containing the correct statement.

• A. A letter of intent is the contractual document that describes the delegated functions and the responsibilities of the MCO and the delegate.
• B. In most cases, the evaluation of a candidate for delegation is based entirely on the candidate’s application and supporting documentation and does not include an on-site assessment of the candidate.
• C. Under most delegation agreements, an MCO cannot terminate the agreement before the end date stated in the agreement.
• D. One objective for a delegation oversight program is to integrate any delegated activities into the MCO’s overall programs for medical management and other functions.

Answer: D

NEW QUESTION 13
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include

• A. focusing on a disabled member’s vocational rehabilitation and training
• B. approving all care decisions for patients under case management
• C. reducing the fragmentation of care that often results when individuals obtain services from several different providers
• D. all of the above

Answer: C

NEW QUESTION 14
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.
In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of

• A. a cosmetic service
• B. an investigational service
• C. an off-label use
• D. a quality-of-life service

Answer: C

NEW QUESTION 15
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 16
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 17
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

NEW QUESTION 18
This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.

• A. American Accreditation HealthCare Commission/URAC (URAC)
• B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• C. Community Health Accreditation Program (CHAP)
• D. National Committee for Quality Assurance (NCQA)

Answer: D

NEW QUESTION 19
The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. An health plan's CRPs reduce the likelihood of errors in decision making.
• B. CRPs typically provide for at least two levels of appeal for formal appeals.
• C. CRPs include only formal appeals and do not apply to informal complaints.
• D. Most complaints are resolved without proceeding through the entire CRP process.

Answer: C

NEW QUESTION 20
By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as

• A. utilization management (UM)
• B. quality management (QM)
• C. care management
• D. clinical practice management

Answer: D

NEW QUESTION 21
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