NEW QUESTION 1
Emilio Martinez, a member of the Bloom Health Plan, has recently been diagnosed with prostate cancer by his physician, Dr. Robert Cohen. Mr. Martinez has decided to participate in Bloom’s shared decision-making program for prostate cancer. On the basis of this information, it is most likely correct to say
* 1. That verification of Mr. Martinez’s understanding about his care options protects both Dr. Cohen and Bloom against charges of malpractice
* 2. That Mr. Martinez and Dr. Cohen will discuss the care options available to Mr. Martinez, but the ultimate decision about care is up to Dr. Cohen

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

Answer: D

NEW QUESTION 2
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms you have chosen.
A primary distinction between skilled care and subacute care relates to the extent and medical complexity of the patient’s needs. Generally, subacute care patients require (more
/ fewer) services from physicians and nurses and (more / less) extensive rehabilitation services than do skilled care patients.

• A. more / more
• B. more / less
• C. fewer / more
• D. fewer / less

Answer: A

NEW QUESTION 3
Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

• A. open / mandatory
• B. open / voluntary
• C. closed / mandatory
• D. closed / voluntary

Answer: C

NEW QUESTION 4
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 5
For this question, if answer choices (a) through (c) are all correct, select answer choice (d). Otherwise, select the one correct answer choice.
Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery processes and outcomes by

• A. providing a framework for care while also allowing for patient-specific variations, based on physician judgment
• B. serving as a basis for evaluating whether providers are practicing in accordance with accepted standards
• C. focusing on the prevention or early detection of a particular condition
• D. all of the above

Answer: D

NEW QUESTION 6
Drugs included in a health plan’s formulary can be classified according to how freely they can be prescribed. By definition, a drug that requires some sort of review or approval by a plan physician or group of physicians before the prescription can be filled is

• A. an unrestricted drug
• B. a monitored drug
• C. a restricted drug
• D. a conditional drug

Answer: B

NEW QUESTION 7
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to

• A. chiropractors
• B. naturopaths
• C. acupuncturists
• D. all of the above

Answer: A

NEW QUESTION 8
Health plans often use accreditation as a means of evaluating the quality of care delivered to plan members. Accreditation of subacute care providers is available from the

• A. National Committee for Quality Assurance (NCQA)
• B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• C. American Accreditation HealthCare Commission/URAC (URAC)
• D. Foundation for Accountability (FACCT)

Answer: B

NEW QUESTION 9
A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
* 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence
* 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
* 3. All of the criteria for coverage decisions must be included in the purchaser contract

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

Answer: B

NEW QUESTION 10
Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for
* 1. Routine eye care
* 2. Clinical eye care

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

Answer: C

NEW QUESTION 11
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 12
The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

• A. combines all existing information from all data sources into a single comprehensive system
• B. connects multiple databases with a central interface engine that acts as an information clearinghouse
• C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database
• D. creates a separate database that pulls pertinent information from the health plan’s claims database, formats the information for easy analysis, and stores it in the separate database

Answer: D

NEW QUESTION 13
One method that health plans use to address provider compliance with formularies is academic detailing.

• A. True
• B. False

Answer: A

NEW QUESTION 14
Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

• A. must be offered as separate supplemental benefits or separate products
• B. lack clinical trials to evaluate their safety and effectiveness
• C. are not covered by state or federal consumer protection statutes
• D. focus on a specific illness, injury, or symptom rather than on the whole body

Answer: B

NEW QUESTION 15
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Under a delegation arrangement, the (delegate / delegator) is responsible for performing the delegated function according to established standards, and the (delegate / delegator) is ultimately accountable for any deficiencies in the performance of the function.

• A. delegate / delegate
• B. delegate / delegator
• C. delegator / delegate
• D. delegator / delegator

Answer: B

NEW QUESTION 16
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