100% Free AHIP AHM-530 Practice Exam Questions Online 2026

Question 1

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in the sameprovider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’spatients are generally healthy and rarely present complications. As a result, Dr. Comer typicallyuses medical resources at a much higher rate than does Dr. Donne. In order to equitably compareDr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation toaccount for differences in the providers’ patient populations and treatment protocols. The healthplan modified Dr. Comer’s and Dr. Donne’s performance data by means of

A : Acase mix/severity adjustment

B : An external performance standard

C : Structural measures

D : Behavior modification

Answer: A

Question 2

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

A : A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.

B : A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.

C : One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.

D : One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer: B

Question 3

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that shecannot sue or file any claims against a Canyon plan member for covered services, even if Canyonbecomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyonwill compensate her under a typical discounted fee-for-service (DFFS) payment system.During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plandetermine how well she met Canyon's standards. The report included cumulative performancedata for Dr. Enberg and encompassed all measurable aspects of her performance. This reportincluded such information as the number of hospital admissions Dr. Enberg had and the number ofreferrals she made outside of Canyon's provider network during a specified period. Canyon alsoused process measures, structural measures, and outcomes measures to evaluate Dr. Enberg'sperformance.The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon planmember for covered services is known as:

A : Atermination with cause clause

B : Ahold-harmless clause

C : An indemnification clause

D : Acorrective action clause

Answer: B

Question 4

The Walnut Health Plan provides a number of specialty services for its members. Walnut offers coverage of alternative healthcare, including coverage of treatment methods such as homeopathy and naturopathy. Walnut also offers home healthcare services, and it contracts with home healthcare providers on a non-risk basis to the health plan. The following statements are about the specialty services offered by Walnut. Select the answer choice containing the correct statement:

A : Homeopathy treats diseases by using small doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated.

B : Naturopathy is an approach to healthcare that uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate.

C : Under a non-risk contract, Walnut most likely transfers the responsibility for arranging home healthcare to the home healthcare provider organizations.

D : Federal law allows Walnut to contract with a home healthcare provider organization only if the provider organization has received accreditation by the Utilization Review Accreditation Commission (URAC).

Answer: A

Question 5

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

A : While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule

B : In general, the ideal negotiating style for provider contracting is a collaborative approach.

C : Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.

D : The actual signing of the provider contract typically takes place after negotiations are completed.

Answer: C

Free AHIP AHM-530 Practice Exam Questions and Answers 2026