Verified AHIP AHM-530 Exam Dumps for Last-Minute Exam Prep

Question No: 1

MultipleChoice

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan's participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot's comprehensive provider contracts. The following statements are about Dr. Zorn's provider contract. Select the answer choice containing the correct statement.

Options

AAll statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.

BBecause the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.

CBecause the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives Dr. Zorn advance notice of its intent to amend the contract.

DAreas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.

Question No: 2

MultipleChoice

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

Options

AConsistent with the symptoms of diagnosis

BFurnished in the least intensive type of medical care setting required by the member's condition

CIn compliance with the standards of good medical practice

DCompared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.

Question No: 3

MultipleChoice

Grant Pelham is covered by both a workers' compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.

Because Mr. Pelham was injured on the job, he is entitled to receive benefits through workers' compensation. Under the terms of the state-mandated exclusive remedy doctrine included in the workers' compensation agreement, Mr. Pelham will most likely be prohibited from

Options

AReceiving workers' compensation benefits unless he can show that the employer was at fault for his injury

BObtaining care from providers who are not members of a workers' compensation network

CSuing his employer for additional benefits

DClaiming benefits from both workers' compensation and his group health plan

Question No: 4

MultipleChoice

The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

Options

Alimit the size of its network to the number of providers necessary to meet the needs of its enrollees

Brequire providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate

Crefuse payment to non-network providers who submit claims for Medicare-covered expenses

Dshift all risk for Medicare-covered services to network providers

Free AHIP AHM-530 Exam Dumps May 2026