QUESTION: 65

Health plans may use different capitation arrangements for different levels of service. One typical capitation arrangement provides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary services. The

global capitation arrangement
gatekeeper arrangement
carve-out arrangement
partial capitation arrangement

Answer(s): D

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QUESTION: 66

Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example

Encounter reports
Diagnostic codes
Durational ratings
Edits

Answer(s): D

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QUESTION: 67

Health plans require utilization review for all services administered by its participating physicians.

True
False

Answer(s): B

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QUESTION: 68

Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl

Low or stable costs.
Appropriate, rather than inappropriate, utilization rates.
A benefit that cannot be easily defined.
Defined patient population.

Answer(s): D

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Free AHM-250 Exam Braindumps (page: 18)

QUESTION: 65

QUESTION: 66

QUESTION: 67

QUESTION: 68

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