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

Medicaid is a joint federal-state program providing coverage to eligible low-income and disabled individuals.

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

Capitation pays a fixed PMPM amount to cover all contracted services, incentivizing efficient coordination.

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

Medicare Part A requires at least 3 consecutive inpatient hospital days before covering SNF care.

Question 4

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

Accepted Answer

A formal mechanism for challenging adverse coverage determinations

Answer

The appeals process provides a mechanism for challenging denied or reduced coverage decisions.

Question 5

What is a bundled payment model?

Accepted Answer

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

Answer

Bundled payments provide a single payment for all services during a defined care episode.

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