CCM - Certified Case Manager Reimbursement and Utilization Management Questions and Answers 3

Question 1

What is the Medicaid program?

Accepted Answer

A joint federal-state program providing health coverage to low-income individuals, families, and people with disabilities

Answer

Identical to Medicare

Answer

A private program for middle-income families

Answer

A military healthcare program

Question 2

What is a capitated payment model?

Accepted Answer

A fixed per-member-per-month payment covering all contracted services regardless of utilization

Answer

Payment based on equipment capital value

Answer

A patient-paid fixed cap

Answer

Only used in government hospitals

Question 3

What is the SNF 3-day qualifying stay requirement?

Accepted Answer

Must have an inpatient hospital stay of at least 3 consecutive days before Medicare covers SNF care

Answer

Must stay exactly 3 days before therapy

Answer

SNF must hold bed for 3 days

Answer

Medicare covers only the first 3 SNF days

Question 4

What is the purpose of the appeals process in utilization management?

Accepted Answer

A formal mechanism for challenging adverse coverage determinations

Answer

Appealing case manager salaries

Answer

Appealing discharge decisions only

Answer

Requesting coverage beyond policy limits

Question 5

What is a bundled payment model?

Accepted Answer

A single payment covering all services during a defined episode of care

Answer

Payment for a bundle of insurance policies

Answer

A bulk discount for supplies

Answer

Combining Medicare and Medicaid benefits

Question 6

What is a Medicaid waiver?

Accepted Answer

An authorization allowing states to waive certain requirements to test innovative approaches, often expanding HCBS

Answer

Waiver of enrollment paperwork

Answer

Waiver of all copayments

Answer

Waiver of provider credentialing