In order for a health plan's performance-based quality improvement programs to be effective, the desired outcomes must be

A. achievable within a specified timeframe

B. defined in terms of multiple results

C. expressed in subjective, qualitative terms

D. all of the above

To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

A. based on Web-based technologies

B. available only to the employees of the health plan

C. publicly available, so the potential exists for unauthorized access to a health plan's proprietary systems

D. used to handle the majority of health plan eCommerce

To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:

Only physicians can make nonauthorization decisions based on medical necessity.

A. True

B. False

When analyzing and applying HRA results, the Multistate Health Plan noted sampling bias. This information indicates that the HRA results

A. do not accurately depict the characteristics of the Multistate member population under study because of errors in data collection

B. are more accurate for individual Multistate members than they are for the total population

C. cannot be stated in numerical terms

D. indicate variation in the number, types, and severity of behavioral risks presented by Multistate's members

Health plans that choose to contract with external organizations for pharmacy services typically contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a health plan include 1.Managing the costs of prescription drugs

2.Promoting efficient and safe drug use 3.Determining the health plan's internal management responsibilities for pharmacy services

A. All of the above

B. 1 and 2 only

C. 2 and 3 only

D. 1 only

For this question, if answer choices (a) through (c) are all correct, select answer choice (d). Otherwise, select the one correct answer choice.

Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery processes and outcomes by

A. providing a framework for care while also allowing for patient-specific variations, based on physician judgment

B. serving as a basis for evaluating whether providers are practicing in accordance with accepted standards

C. focusing on the prevention or early detection of a particular condition

D. all of the above

To improve members' abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.

A. The primary role of telephone triage clinical staff is to diagnose the caller's condition and give medical advice.

B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.

C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.

D. A telephone triage program may also include a self-care component.

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

The Balanced Budget Act (BBA) of 1997 established the use of ___________ to determine coverage of emergency services for Medicare and Medicaid enrollees in health plans.

A. utilization management standards

B. the prudent layperson standard

C. preauthorization

D. diagnosis-based retrospective review

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

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for 1.Routine eye care 2.Clinical eye care

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2