CCM Reimbursement and Utilization Management 2

Question 1

A patient's insurer denies a claim stating the service was 'not medically necessary.' What is the case manager's FIRST step?

Accepted Answer

Review the clinical criteria used for the denial and compare with the patient's documentation

Answer

Reviewing the denial criteria against clinical documentation helps identify whether a peer-to-peer review or formal appeal is warranted.

Question 2

Which payment model reimburses a provider a fixed amount per member per month regardless of services rendered?

Accepted Answer

Capitation

Answer

Capitation pays a set monthly fee per enrolled member, transferring financial risk to the provider.

Question 3

Under Medicare, what is the purpose of the Advance Beneficiary Notice (ABN)?

Accepted Answer

To inform a beneficiary that Medicare may not cover a service so they can decide whether to proceed

Answer

An ABN alerts Medicare beneficiaries in advance that a specific service may be denied, allowing an informed financial decision.

Question 4

A case manager is conducting concurrent review for an inpatient stay. What is the primary goal of this activity?

Accepted Answer

Ensure continued hospitalization is medically justified and facilitate timely discharge planning

Answer

Concurrent review monitors ongoing medical necessity for inpatient care and promotes efficient, appropriate length of stay.

Question 5

Which federal program provides health coverage to individuals with end-stage renal disease (ESRD) regardless of age?

Accepted Answer

Medicare

Answer

Medicare covers individuals with ESRD under a special entitlement, making age irrelevant for this specific condition.

CCM - Certified Case Manager Exam Practice Test