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AHM-530 – Network Management

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Showing 4–6 of 15 questions

Question 4 (Volume A)

Most health plan contracts provide an outline of the criteria that a healthcare service must meet in order to be considered “medically necessary.” Typically, in order for a healthcare service to be considered medically necessary, the service provided by a physician or other healthcare provider to identify and treat a member’s illness or injury must be

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  • ○

    Consistent with the symptoms of diagnosis

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    Furnished in the least intensive type of medical care setting required by the member’s condition

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    In compliance with the standards of good medical practice

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    All of the above
Question 5 (Volume B)

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

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  • ○

    Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.

    Both A and B
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    Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.


    A only
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    B only
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    Neither A nor B
Question 6 (Volume B)

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:

Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.

Foxfire's per member per month (PMPM) capitation for dermatology services is $1.

The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.

During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

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    that the value of each referral point for the first quarter was $120
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    that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000
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    that the payment that Foxfire owed Dr. Rashad for the first quarter was $6,120
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    all of the above