QUESTION: 45

Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.
UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.
The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.
The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.

Answer(s): D

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QUESTION: 46

Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network.
Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim

A, B, C, and D
A and C only
A, B, and D only
B, C, and D only

Answer(s): A

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QUESTION: 47

Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by

Confinement in the extended-care facility after his hospitalization.
Transportation by ambulance from the hospital to the extended-care facility.
Physicians' professional services while he was hospitalized.
physicians' professional services while he was at the extended-care facility.

Answer(s): A

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QUESTION: 48

Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:

Provides Ms. Giambi with healthcare coverage for any illness or injury, but only if the cause of the illness or injury is work-related.
Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage.
Requires Ms. Giambi and her employer to each pay half of the cost of this coverage.
Requires Ms. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.

Answer(s): B

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Free AHM-250 Exam Braindumps (page: 13)

QUESTION: 45

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QUESTION: 47

QUESTION: 48

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