- (Topic 2)
The Aztec Health Plan has a variety of organizational committees related to quality and utilization management. These committees include the medical advisory committee, the credentialing committee, the utilization management committee, and the quality management committee. Of these committees, the one that most likely is responsible for providing oversight of Aztec's inpatient concurrent review process is the:

1. A. medical advisory committee
2. B. credentialing committee
3. C. utilization management committee
4. D. quality management committee

Correct Answer: C

- (Topic 1)
A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

1. A. provisions for marketing the plan’s product
2. B. payment arrangements between the plan and the provider
3. C. verification of the plan’s eligibility to do business
4. D. management of the contents of members’ medical records

Correct Answer: B

- (Topic 1)
Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

1. A. Allow members direct access to OB/GYN services
2. B. Allow members direct access to prescription drug services
3. C. Provide access to Title X family-planning clinics
4. D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Correct Answer: D

- (Topic 1)
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.
In most states, a health plan can be held responsible for a provider’s negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements,marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).

1. A. Vicarious liability / employees of the health plan
2. B. Vicarious liability / independent contractors
3. C. Risk sharing / employees of the health plan
4. D. Risk sharing / independent contractors

Correct Answer: B

- (Topic 1)
The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation ’99. One statement that can correctly be made about these accreditation standards is that

1. A. Health plans are required by law to report HEDIS results to NCQA
2. B. HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
3. C. Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
4. D. HEDIS includes measures of a health plan’s effectiveness of care rather than its cost of care

Correct Answer: C