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AHIP AHM-530 Exam Questions
- Topic 1: Map out how health insurance providers select, contract with, and compensate specialists and health care facilities/ Learn the process for network provider selection
- Topic 2: Recognize special requirements that affect network management for Medicare, Medicaid, and workers’ compensation networks
- Topic 3: Gain a detailed understanding of the scope and organization of the network management function within health insurance provider organizations
- Topic 4: Explore how health insurance providers ensure their provider networks remain adequate to meet member needs/ Understand how network strategies improve access, quality, and cost-effectiveness
- Topic 5: Identify the primary responsibilities and obligations of health insurance providers and health care providers under a provider contract
- Topic 6: Master the essential elements of a contractual relationship between health insurance providers and health care providers
Free AHIP AHM-530 Exam Actual Questions
Note: Premium Questions for AHM-530 were last updated On Apr. 10, 2025 (see below)
In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
A formulary lists the drugs and treatment protocols that are considered to be the preferred therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members' prescription drugs than it would if it did not use a formulary.
In developing a provider network in an large city with a high concentration of young families, the Gypsum Health Plan has set goals focused on the needs of that particular market. The following statements are about this situation. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.
The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:
The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA, The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
From the following answer choices, select the response that best identifies Elm and Treble:
When evaluating the success of providers in meeting standards, a health plan must make adjustments for case mix or severity. One true statement about case mix/severity adjustments is that they:
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