Free AHM-530 Exam Braindumps

- (Topic 2)
The Elizabethan Health Plan uses a direct referral program, which means that

1. A. PCPs in Elizabethan’s network can make most referrals without obtaining prior authorization from Elizabethan
2. B. PCPs in Elizabethan’s network must always refer plan members to other specialists within the network
3. C. Elizabethan’s plan members can bypass the PCP and obtain medical services from a specialist without a referral
4. D. Elizabethan’s plan members must obtain referrals directly from Elizabethan

Correct Answer: A

- (Topic 2)
In 1996, the NAIC adopted a standard for health plan coverage of emergency services. This standard is based on a concept known as the:

1. A. Due process standard
2. B. Subrogation standard
3. C. Corrective action standard
4. D. Prudent layperson standard

Correct Answer: D

- (Topic 2)
Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis- related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

1. A. typically allow for the assignment of multiple classifications for an outpatient visit
2. B. always apply to a patient's entire hospital stay
3. C. typically serve as a payment system for inpatient services
4. D. typically include reimbursements for professional fees

Correct Answer: A

- (Topic 2)
The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

1. A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.
2. B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.
3. C. Both A and B
4. D. A only
5. E. B only
6. F. Neither A nor B

Correct Answer: A