Health plans arrange for the delivery of various levels of healthcare, including
* 1.Emergency care
* 2. Urgent care
* 3. Primary care delivered in a provider’s office
In a ranking of these levels of care according to cost, beginning with the least expensive level of care and ending with the most expensive level of care, the correct order would be
Correct Answer:
D
The following statement(s) can correctly be made about utilization guidelines:
* 1. When developing utilization guidelines, health plans balance evidence-based criteria with experience-based criteria
* 2. Utilization guidelines indicate when a UR nurse should refer a decision to a physician reviewer
Correct Answer:
A
Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance:
* 1. Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance
* 2. Special cause variance is typically more difficult to detect and correct than is common cause variance
Correct Answer:
B
Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden
Correct Answer:
C
The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as
Correct Answer:
D