Question 1

Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

Options :

A :

cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations

B :

diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care

C :

patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes

D : the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

Answer: D

Question 2

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

Options :

A : chiropractors

B : naturopaths

C : acupuncturists

D : all of the above

Answer: A

Question 3

One true statement about state regulation of case management activities is that the majority of states

Options :

A :

have enacted laws that list specific quality management requirements for a case management program

B :

consider case management files to be medical records that must be retained for a specified length of time

C : view case management similarly and follow similar patterns with their laws and regulations

D : have enacted laws or regulations requiring licensure or certification of case managers

Answer: B

Question 4

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

Options :

A : All of the above

B : 1 and 2 only

C : 2 only

D : 3 only

Answer: B

Question 5

Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden

Options :

A : must pay the entire cost of the examination

B : must obtain a referral to a dentist from her primary care provider (PCP)

C : can schedule the examination without preauthorization of payment by the DHMO

D : can schedule an unlimited number of examinations and cleanings per year

Answer: C

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