AHM-250 Certification Exam Questions with AI Explanations

QUESTION: 66

Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example

Encounter reports
Diagnostic codes
Durational ratings
Edits

Answer(s): D

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QUESTION: 67

Health plans require utilization review for all services administered by its participating physicians.

True
False

Answer(s): B

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QUESTION: 68

Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl

Low or stable costs.
Appropriate, rather than inappropriate, utilization rates.
A benefit that cannot be easily defined.
Defined patient population.

Answer(s): D

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QUESTION: 69

Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is that

users can access the Internet using a number of different types of computer systems
access to the Internet is available only to members of the health plan's network
the Internet is immune to internal security breaches by employees or trading partners within the network
users can contact a single controlling organization to rectify disruptions in Internet service

Answer(s): A

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