NEW QUESTION 1
One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the

• A. appropriate dosages, duration of treatment, and other elements related to the use of a particular drug
• B. actual prescribing and dispensing patterns for a particular drug
• C. types of diseases, conditions, or patients for which a drug should be used
• D. cost-effectiveness of all possible drug treatments for a particular condition

Answer: A

NEW QUESTION 2
Breanna Osborn is a case manager for a regional health plan. One component of Ms. Osborn’s job is the collection and evaluation of medical, financial, social, and psychosocial information about a member’s situation. This component of Ms. Osborn’s job is known as

• A. case identification
• B. case management planning
• C. healthcare coordination
• D. case assessment

Answer: D

NEW QUESTION 3
Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which
* 1.A significant percentage of those treated with the initial therapy will require the second therapy
* 2.The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects

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

Answer: C

NEW QUESTION 4
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 5
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 6
Determine whether the following statement is true or false:
Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.

• A. True
• B. False

Answer: B

NEW QUESTION 7
The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

• A. evaluate all providers without considering differences in risk
• B. focus on specific clinical decisions of Garnet’s providers rather than on patterns of care
• C. identify the outliers and high-value providers in its provider network
• D. measure the effectiveness, but not the efficiency, of Garnet’s providers

Answer: C

NEW QUESTION 8
Three general categories of coverage policy—medical policy, benefits administration policy, and administrative policy—are used in conjunction with purchaser contracts to determine a health plan’s coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan’s

• A. medical policy evaluates clinical services against specific benefits language rather than against scientific evidence
• B. benefits administration policy determines whether a particular service is experimental or investigational
• C. benefits administration policy focuses on both clinical and nonclinical coverage issues
• D. administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes

Answer: D

NEW QUESTION 9
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Medical management programs often require the analysis of many types of data and information. ________ is an automated process that analyzes variables to help detect patterns and relationships in the data.

• A. Unbundling
• B. Outsourcing
• C. Data mining
• D. Drilling down

Answer: C

NEW QUESTION 10
Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

• A. Health plans rarely delegate HRA activities to external entities
• B. Health plans typically focus their HRA efforts on newly enrolled members
• C. HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members
• D. HRA is generally a reliable predictor of medical resource utilization

Answer: B

NEW QUESTION 11
The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
* 1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
* 2.The National Committee for Quality Assurance (NCQA)
* 3.The American Accreditation HealthCare Commission/URAC (URAC)

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

Answer: B

NEW QUESTION 12
The case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:
Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24- hour medical care.
Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.
From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.

• A. M
• B. Morton-acute care M
• C. Finley-subacute care
• D. M
• E. Morton-palliative care M
• F. Finley-acute care
• G. M
• H. Morton-subacute care M
• I. Finley-skilled care
• J. M
• K. Morton-skilled care M
• L. Finley-palliative care

Answer: C

NEW QUESTION 13
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 14
In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

• A. achievable within a specified timeframe
• B. defined in terms of multiple results
• C. expressed in subjective, qualitative terms
• D. all of the above

Answer: A

NEW QUESTION 15
Determine whether the following statement is true or false:
All health plans participating in the Federal Employee Health Benefits Program (FEHBP) are required to use the Consumer Assessment of Health Plans (CAHPS) to measure customer satisfaction.

• A. True
• B. False

Answer: A

NEW QUESTION 16
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