AHIP Medical Management : AHM-540

All states have laws describing the conditions under which pharmacists can substitute a
generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

• A. pharmacists must obtain authorization from the health plan before substituting generics for brand-name drugs
• B. pharmacists must obtain physician approval before substituting generics for brand-name drugs
• C. prescribers have some mechanism that allows them to prevent pharmacists from substituting generics for brand-name drugs
• D. prescribers must obtain authorization from the health plan before prescribing a brand-name drug

The following statement(s) can correctly be made about the scope of case management:
1.Case management incorporates activities that may fall outside a health plan's typical responsibilities, such as assessing a member's financial situation
2.Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review
3.Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs

• A. 1 only
• B. 1 and 2 only
• C. 2 and 3 only
• D. All of the above

The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals:
1.A discounted fee-for-service (DFFS) payment system
2.A case rate system
3.Capitation
If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include

• A. 1 and 2 only
• B. 2 and 3 only
• C. 1, 2, and 3
• D. 3 only

The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. A health plan's UR program is usually subject to review and approval by the state insurance and/or health departments.
• B. UR recommends the procedures that providers should perform for plan members.
• C. UR evaluates whether the services recommended by a member's provider are covered under the benefit plan.
• D. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select the term or phrase in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms or phrases you have chosen.
TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

• A. appeals / TRICARE contractor
• B. grievances / TRICARE contractor
• C. appeals / Area Field Office
• D. grievances / Area Field Office