CCM Reimbursement and Utilization Management 3

Question 1

Which utilization management strategy involves evaluating a proposed service BEFORE it is provided to determine medical necessity?

Accepted Answer

Prospective review (prior authorization)

Answer

Prospective review, commonly known as prior authorization or pre-certification, assesses medical necessity before a service is delivered.

Question 2

Which of the following best defines a 'carve-out' benefit in managed care?

Accepted Answer

A benefit excluded from the standard plan but covered under a separate specialized contract

Answer

Carve-out benefits, such as behavioral health or pharmacy, are separated from the main medical plan and managed by a specialty vendor.

Question 3

Under the Mental Health Parity and Addiction Equity Act (MHPAEA), how must insurers treat mental health and substance use disorder benefits?

Accepted Answer

Mental health benefits cannot be subject to more restrictive limitations than comparable medical/surgical benefits

Answer

MHPAEA prohibits insurers from imposing more restrictive financial requirements or treatment limitations on mental health/SUD benefits than on medical/surgical benefits.

Question 4

A case manager identifies that a patient is being kept in an acute care bed primarily for social reasons, not medical ones. What is the most appropriate action?

Accepted Answer

Initiate discharge planning to identify appropriate post-acute or community resources

Answer

When medical necessity for acute care no longer exists, the case manager should proactively identify appropriate placement or community supports.

Question 5

What is the primary function of a formulary in pharmacy benefit management?

Accepted Answer

A tiered list of covered medications used to guide prescribing and control drug costs

Answer

A formulary is a preferred drug list organized in tiers that determines coverage level and cost-sharing for medications.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Reimbursement and Utilization Management 3