CCM - Certified Case Manager Reimbursement and Utilization Management Questions and Answers 2

Question 1

What is the primary difference between Medicare Part A and Part B?

Accepted Answer

Part A covers inpatient/institutional services; Part B covers outpatient/professional/preventive/DME services

Answer

Part A covers inpatient and institutional services; Part B covers outpatient, professional, and preventive services.

Question 2

What is prior authorization and the case manager's role?

Accepted Answer

Insurance approval before certain services, with the case manager facilitating clinical documentation

Answer

Prior authorization requires insurance approval before certain services, with case managers providing clinical justification.

Question 3

What is a Diagnosis-Related Group (DRG)?

Accepted Answer

A patient classification determining fixed reimbursement based on diagnosis, procedures, age, and complications

Answer

DRGs classify inpatient stays into groups with fixed payment amounts regardless of actual costs.

Question 4

What is the difference between prospective, concurrent, and retrospective utilization review?

Accepted Answer

They differ by timing: prospective before, concurrent during, retrospective after care delivery

Answer

The three types differ by timing relative to care delivery: before, during, and after.

Question 5

What is a Medicare Advantage plan?

Accepted Answer

An alternative to Original Medicare offered by private insurers providing all Part A/B benefits through managed care

Answer

Medicare Advantage (Part C) is offered by private insurers as an alternative providing Part A/B benefits through managed care networks.

CCM - Certified Case Manager Exam Practice Test