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AHM-530 dumps questions answers

AHIP AHM-530 Dumps

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Network Management
Last Update: Feb 27, 2024
202 Questions
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Network Management Practice Questions

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Network Management Questions and Answers

Questions 1

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must



Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider


Base a provider’s participation in the network, reimbursement, and indemnification levels on the provider’s license or certification


Define its service area according to community patterns of care


Require enrollees to obtain prior authorization for all emergency or urgently needed services

Questions 2

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:










Questions 3

The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:

• Brian Pollard received treatment for a torn retina he suffered as a result of an accident

• Angelica Herrera received a general eye examination to test her vision

• Megan Holtz received medical services for glaucoma

Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:



Mr. Pollard, Ms. Herrera, and Ms. Holtz


Mr. Pollard and Ms. Herrera only


Mr. Pollard and Ms. Holtz only


Ms. Herrera and Ms. Holtz only