QUESTION: 85

In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of

Prospective review
Concurrent review
D, A, B, and C
A and B only
A and C only
B only

Answer(s): C

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QUESTION: 86

In claims administration terminology, a claims investigation is correctly defined as the process of

reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patterns
obtaining all the information necessary to determine the appropriate amount to pay on a given claim
routinely reviewing and processing a claim for either payment or denial
assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatment

Answer(s): B

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QUESTION: 87

In health plan terminology, demand management, as used by health plans, can best be described as:

an evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans for a given patient
a series of strategies designed to reduce plan members' needs to utilize healthcare services by encouraging preventive care, wellness, member self-care, and appropriate use of healthcare services
a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that exceed the maximum fee reimbursed by the plan
a system of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those needs, and coordinating and monitoring the care

Answer(s): B

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QUESTION: 88

In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the

chief executive officer (CEO)
network management director
board of directors
director of operations

Answer(s): B

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