CCM Healthcare Regulations & Compliance 3

Question 1

A care manager working in a managed care organization receives a request to deny coverage for a service deemed medically necessary by the treating physician. What regulatory framework governs the appeal process?

Accepted Answer

State and federal utilization review and external review laws

Answer

State utilization review laws and federal requirements under the ACA mandate specific internal appeal and external independent review processes when coverage for medically necessary services is denied.

Question 2

The Medicare Conditions of Participation (CoPs) for home health agencies require that a plan of care be reviewed and signed by a physician at least every:

Accepted Answer

60 days

Answer

Medicare CoPs require that the home health plan of care be reviewed by the physician and agency at least every 60 days, coinciding with the certification period.

Question 3

Which federal law prohibits discrimination based on race, color, national origin, disability, age, and sex in health programs receiving federal financial assistance?

Accepted Answer

Section 1557 of the Affordable Care Act

Answer

Section 1557 of the ACA is the first federal civil rights law prohibiting discrimination based on multiple protected characteristics specifically in health programs and activities receiving federal financial assistance.

Question 4

What is the primary purpose of a Business Associate Agreement (BAA) under HIPAA?

Accepted Answer

To establish the contractual obligation of vendors handling PHI to protect that information

Answer

A BAA is a contract between a HIPAA covered entity and a business associate that establishes the permitted uses of PHI and ensures the business associate will safeguard the information.

Question 5

Under the Omnibus Budget Reconciliation Act (OBRA) 1987, nursing facilities must conduct a comprehensive assessment of each resident using which standardized tool?

Accepted Answer

Minimum Data Set (MDS)

Answer

OBRA 1987 mandates that nursing facilities use the Minimum Data Set (MDS) as part of the Resident Assessment Instrument to conduct comprehensive assessments for care planning.

(CCM) Certified Care Management Professional Practice Test

(CCM) Certified Care Management Professional Practice Test

CCM Healthcare Regulations & Compliance 3