CCMC Utilization Management 2

Question 1

What does 'level of care' determination refer to in utilization management?

Accepted Answer

The assessment of the appropriate care setting based on a patient's clinical needs

Answer

Level of care determination assesses whether a patient requires inpatient, observation, skilled nursing, or outpatient care based on clinical criteria.

Question 2

Under the utilization management process, 'medical necessity' is BEST defined as:

Accepted Answer

Care that is clinically appropriate, evidence-based, and required to diagnose or treat a condition

Answer

Medical necessity refers to care that is clinically appropriate and evidence-based, required to diagnose or treat a condition, and not primarily for convenience.

Question 3

Retrospective utilization review is MOST useful for:

Accepted Answer

Identifying patterns of over- or under-utilization after care is delivered

Answer

Retrospective review analyzes care that has already occurred to identify utilization patterns, billing accuracy, and potential overuse or underuse of services.

Question 4

Which federal law requires health plans to establish an internal and external appeals process for denied claims?

Accepted Answer

The Affordable Care Act (ACA)

Answer

The ACA mandates that health plans provide both internal and external appeals processes for denied or terminated coverage decisions.

Question 5

In utilization management, discharge planning should ideally begin:

Accepted Answer

At the time of admission or as early in the stay as possible

Answer

Effective discharge planning begins at admission or as early as possible to identify post-acute needs and ensure a safe, timely care transition.

CCMC - Commission for Case Manager Certification Practice Test

CCMC - Commission for Case Manager Certification Practice Test

CCMC Utilization Management 2