AHIP AHM-530 Exam Practice Questions (P. 1)

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as:

Decide whether the following statement is true or false:
The organizational structure of a health plan's network management function often depends on the size and geographic scope of the health plan. With respect to the size of a health plan, it is correct to say that smaller health plans typically have less integration and more specialization of roles than do larger health plans.

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plan's provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan's pre-established criteria for participation in the network.

One important aspect of network management is profiling, or provider profiling. Profiling is most often used to:

Network managers rely on a health plan's claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan's claims administration department enables the health plan to: