CCM EXAM 300 Questions with Verified Answers
ACO - CORRECT ANSWER An acronym for Accountable Care Organization
Actuary - CORRECT ANSWER A person in
... [Show More] the insurance field who decides insurance policy rates and reserves dividends, as well as conducts various other statistical analyses
Parternship for Health ACT 1966 - CORRECT ANSWER recognized health promotion and illness prevention as a " State of complete physical, mental, social well being
Assessment tool and diagnostic tests - CORRECT ANSWER tools used for evaluating risk and outcomes asessment tool
Glascow coma scale and Ranchos Los Amigos( cogitive scale) - CORRECT ANSWER tools used to access brain injured patients
psychiatric disability - CORRECT ANSWER term that can be associated with various types of illness or injury not just psych
HAART - CORRECT ANSWER highly active antiretroviral therapy
Psychiatric Disablity - CORRECT ANSWER a silent comborid condition can affect a patients physical health and quality of life
Dual Diagnosis - CORRECT ANSWER Substance abuse and mental health combined diagnosis
polypharmacy - CORRECT ANSWER unintended duplication of drugs that usually results when patients see multiple physicians or frequent numerous pharmacies using homeopathic, supplemental,or OTC or herbal medcicnes also put individuals at risk for what?
unintentional polypharmacy - CORRECT ANSWER seeking competitive drug pricing or when useing various pharmacies with locations near work, home, social events. See it in older adults who visist mutliple physicians
Managed Care OrganIzation ( MCO) - CORRECT ANSWER what can help prevent polypharmacy
intentional polypharmacy - CORRECT ANSWER addicted to drugs is an example of
IT software systems - CORRECT ANSWER IT software now can notify ordering MD about potential abuses ie polypharmacy. Can interface with disease managment where pharmacy daa and claims data are used to stratify health patterns and health profiles of patients
Blinking light for MD's - CORRECT ANSWER taking 5 or more medications
using different pharmacies to fill scripts
chronic pain - CORRECT ANSWER people you have chronic pain develop a dependency fro a pain med regimen that allows them to tolerat their daily living activites and lead a fairly normal life. they do get the label of addicted drug-seeking patients
BASIS 32 - CORRECT ANSWER a common and effective assessment tool for the patient suspected of having substance abuse/mental health
Identification of patient - CORRECT ANSWER First step in CM process
utlizization managament - CORRECT ANSWER computer software helps ID cases for CM flag the ones that exceed a certain amount of money or hospitlization is found in which department
consultation - CORRECT ANSWER the act of conferring with another individual for the purpose of gaining an opinion or advice is known as
physician - CORRECT ANSWER keep decision maker
autocratic - CORRECT ANSWER sole responsbility legally and ethically for physicians can be
Medication Thearpy Managment - CORRECT ANSWER used in Medicare and Medicaid part B
collaboration/communication - CORRECT ANSWER The glue that binds all the process of Case management together
frontal lobe injury - CORRECT ANSWER problems with activities
involving planning, organizing and problem solving
poor attention
personality changes
occipital lobe - CORRECT ANSWER visual problems
Temporal lobe - CORRECT ANSWER short term memory loss
inablity to process information
smell and sound deficienies
Left parietal lobe - CORRECT ANSWER written spoken language problem
right partietal lobe - CORRECT ANSWER visual deficits
diffculty negotiating new or familar places
C3 or higher - CORRECT ANSWER vent support
T6 or higher - CORRECT ANSWER autonomic dysreflexia a life threatening condition that presents with a pounding headache, profuse sweating episodic high blood pressure, bradycardia
lumbar spine - CORRECT ANSWER paraplegia
sacral spine - CORRECT ANSWER assistive devices when ambulating( cane walker braces)
autonomic dysreflexia - CORRECT ANSWER full bladder, fecal impaction, tight clothing
Benchmarking - CORRECT ANSWER the ongoing process of measuring products, services, and practices against competitors or leaders in a given specialty
Case Managment - CORRECT ANSWER a managment technique to achieve opitmal otucomes and efficient resource utilization for a given patient population
continous quality improvement - CORRECT ANSWER the cyclical process to assess, measure, change a process, re-measure, and reassess for ongoing incremental improvments
Outcomes Managment - CORRECT ANSWER The process of assessing mutliple factors including casre effectiveness, side effects, adminsistrative and geneal costs, and patient satisfaction
Practice Parameters - CORRECT ANSWER the pulbished guidelines for patient managmened which includes proctocols, critical paths, and algorithms
Re-engineering - CORRECT ANSWER Fundamental rethinking and radical redesign of business processes to achieve dramatic improvments in measures of preformance
Value Analysis - CORRECT ANSWER balancing the cost and quality effects of care by improving care delivery processess, and eliminating unnecessary care variances
Disease Management - CORRECT ANSWER The continous porcess of identigying and delivering the most efficinet combination of resources for the treatment or prevnetion of disease, within a selected patient population
preclinical - CORRECT ANSWER invivo, invitro
Phase 1 - CORRECT ANSWER first times in humans
Phase 2 - CORRECT ANSWER exploratoy
Phase 3 - CORRECT ANSWER confirmatory
phase 4 - CORRECT ANSWER post marketing
P-value porpability - CORRECT ANSWER 0.0-1.0 < 0.05 statistically significant
Single Blind - CORRECT ANSWER investigator knows treamtent paitent is receiveing
open label - CORRECT ANSWER both the patient and investigator know the treatment patient is receiving
Double blind - CORRECT ANSWER neither investigator nor pt know treament patient is receiving
Compartive effectiveness - CORRECT ANSWER a rigorous evaluation of the impact of different opitons that are available for treating a given medical condition for apraricualr set of patients
Comparive effectiveness research - CORRECT ANSWER to assist consumers and clinicians, purchasers, and policy makers to make informed decisions that will imporve health care at both the individual and population level. This helps CM to appropriatley influncene patient decisions
... - CORRECT ANSWER Case managers need to understand and embarace evidence before teaching others, get in the habit of reviewing pertinent evidence in the literature.
Accountable Care OrganIzation - CORRECT ANSWER an entity charged with the bundling of care services of hospitals, physicians, other entities and care providers who are delivering services during an episode of care. Providers/organIzations share in the cost savings achieved as a result of coordination
Adjudication - CORRECT ANSWER the process of completing all validity, process, and file edits necessary to prepare a claim for final payment or denial, or the processing of a claim through a series of edits to determine proper payment.
ADL - CORRECT ANSWER an acronym for " activites of daily living"
Adminstrative Costs - CORRECT ANSWER The Costs assumed by a managed care plan for administrative servies, such as claims processing, billing, and overhead costs
Adverse Selection - CORRECT ANSWER The risk of enrolling members who are sicker and will require more medical services than initially assumed and who will utilize more expensive servies more frequently
Affordabale care Act - CORRECT ANSWER another name for Patient Protection and Affordable care Act
Aftercare - CORRECT ANSWER services adminsistered after hopsitalization or rehabilitation that are individualized fro each patient's needs
Age/Sex Rating - CORRECT ANSWER structuring premium payments based on members age and gender
AHA - CORRECT ANSWER an acronym for American Hospital Association
AIDS - CORRECT ANSWER an acronym for Acquired Immunodeficiency Syndrome
Alcoholism - CORRECT ANSWER A mental and/or physical depenence on alcohol due to chronic and habitual use
Alcoholism or Drug addiction treatment facility - CORRECT ANSWER a legally operated, free standing facility or clinic, or part of a hospital that specializes in alcohol or drug adiction treatment programs. these porgrams operate under the direction of Doctors of Medicine or Doctors of Osteopathy, having nursing servies and are accredited by the Joint Commission ( JCAHO) or meet similar standards
Allowable Charge - CORRECT ANSWER a charge based on amounts accepted by other providers in the area of similar treatment, care services or supplies. It is the maxium fee that a third pary will reimburse a provider for a given service
ALOS - CORRECT ANSWER An acronym for " Average length of stay" It is a benchamark average used for analysis of utilization. It is calcualted as the average number of patient hospitalization days for each admission, articulated as an average of populationw within the paln for a given period of time
Alternate Care - CORRECT ANSWER meidcal care received in lieu of inpatient hospitalization. Examples include outpatient surgery, home health care, and skilled nursing facility care. It also may refer to non-traditional care delivered by providers such as midwives
AMA - CORRECT ANSWER an acronym for American Medical Association
Ambulatory Care - CORRECT ANSWER health services delivered on an outpatient basis. If a patient has an appiontment in hte doctors office or a surgical center without an overnight, it is considcered ambulatory care
Ambulatory Setting - CORRECT ANSWER A type of health care setting where health servies are provided on an outpatinet basis. Ambulatory setting usually include physician's offices, clinics, and surgery centers
Ambulatory Surgery - CORRECT ANSWER A surgical procedure in which the paitent is admitted, treated, and released on the same day
Ambulatory Surgical Center - CORRECT ANSWER a legally operated facility that specializes in surgical procedures and has a staff of Doctors of Medicine or Doctors of Osteopahty, along with RN services. An ambulatory srugical center does not have facilities of patients to stay overnight, and it is acredited by the Accreditation Association for ambulatory healthcare or meets similar standards
Appeal - CORRECT ANSWER a formal request by a covered person or provider for resconsideration of a decision,k such as a utilization review recommendation, a benfit payment( claim) or administrave action
ASO - CORRECT ANSWER An acronym for porviding " administrative service only. It is a contract stipulation between a plan and inurance cmpany in which the insurance company assumes no risk and provides only adminstratrive services for a fixed fee per employee
Assignment - CORRECT ANSWER An arrangement in which the provider submits the claim on behalf of hte aptient and is reimbursed direclty by the patients plan.
Authoriation ( also called Pre-authoriation or Pre-certification - CORRECT ANSWER In managed care it r3efers to the approval of care, such as a hospitalization, certain diagnositce test, or even non covered medications. Preauthoiration may be required before admisttion takes plan or care is given by non-managed care providers
AWP - CORRECT ANSWER When referring to medications, it is an acronym for " average wholesale price". It is the pulished average cost of a drug product by the pharmacy to the wholesaler. It is psecific to drug strength, dosage from ( capsule, tablet solution, vial) package size, and manufacturer or labeler. When it is not referring to medications, this abbreviation also stands for " any willing provider " Statues requiring a provider network to accept any provider who meets the network's usual selection criteria
Behavioral Health Care - CORRECT ANSWER Treatment of menatla health and/or substanc abuse disorders
Beneficiary - CORRECT ANSWER any peson or persons named by a policyholder to receive the policy holder's insurance benefits or coverage
Benefit Level - CORRECT ANSWER The limit or degree of services a person is entitled to receive based on his or her contract with health plan or insurer
Benefit Package - CORRECT ANSWER th services an insurer, goverment agency,health plan, or employer offers under the terms of a contract
Cafeteria Plan - CORRECT ANSWER a corporate benefits plan under which all employees are permitted to choose among two or more benefits that consist of cash and certain qualifed benefits. Cafteteria plans are also called flexible benefit plans or flex plans
Calendar year - CORRECT ANSWER The inclusive period of time from January 1 of any year through December 31 of the same year. This is most often used in connection with deductible amount provisions of major medical plans providng benefits for expenses incurred within the calendar year.
CapM - CORRECT ANSWER the contract maximum, which is the limit or " cap that the insurance cmpnay will pay out for a given individual.
Capitation - CORRECT ANSWER A method of payment used in manged care as per-member monthly payment to a provider that covers contracted servies and is paid in advance of its delivery. In essence, a provider agrees to provide specified sdrvies to health plan members usually in a health maintenance organization( HMO) for this fixed, predetermine payment for a specified lenth of time( usually a year) regardless of how many times the member uses the service. The rate can be fixed for all members or it can be adjusted for the age and sex of the member, based on actuarial projections of medical utilization
Carrier - CORRECT ANSWER The insurance company which holds the financial risk and is responsible for adminstering the plan benefits
Certificate of Coveage - CORRECT ANSWER a descripiton of the benefits included in a carrier's plan. The certificate of coverage is required by state laws and respresents the coverage provided under the contract issued to the employer
CHAMPUS - CORRECT ANSWER An acronym of Civilian health and Medical Program of the Unifored Services. Is the federal medical beneifts reimbursment program for dependents of military personnel, military retirees, and others. It is now known as TRICARE
Charge - CORRECT ANSWER A charge is deemed to incurred on the date on which th treatment, care services or supply is made or given. If it is not shown otherwise and a single charge is made for a series of treatments, servies, supplies, or care sessions each will be deemed to bear a pro rata share of the charge
Chemical Dependency Services - CORRECT ANSWER Servies and supplies used in the diagnosis and treament of alcoholism, chemical dependency, and drug dependency which is defined and classifed by the US department of Health and Human Services
Claim Lag - CORRECT ANSWER service and its submission; as well as the time between the incurred date of the claim and its payment.
Claim Manual - CORRECT ANSWER Th administrative guidelines used by claims processors to process claims according to company policy and procdure.
Claims Reviewer - CORRECT ANSWER a payer employee who reviews claims like an auditor,looking at coding, prior authorizations, contract viloations etc
Clinical Peer Reviewer - CORRECT ANSWER A health care professional that holds license in at least one state, who is in the same or similar specialty as the medical condition, procedure, or treatment being subjected to utilization review, and who routinely provides the heatlh care services being subjected to utilization review
COB - CORRECT ANSWER an acronym for " coordination of benefits". It is an agreement that prevents double payment for services when the member is covered by two or more sources. the agreement dictates which organization is primarliy and secondarily responsible for payment.
COBRA - CORRECT ANSWER An acronym for Consilidated Omnibus Reconciliation Act. IT is the legislation that in part requires employers to offer terminated employees the opportunity to continue buying insurance coverage as part of the employee's group
Coinsurance - CORRECT ANSWER The percentage of the costs of medical servies paid by the patient. It is a characteristic of different types of insurance plans, including managed care plans. The coinsurance payment is usually about 20 % of the cost of the medical servies after the deductible is paid
Comorbidity - CORRECT ANSWER Pre-existing conditions that cause an increase in length of stay by at least one day in ~75% percent of case. It is used in DRG reimbursment
Concurrent review - CORRECT ANSWER a screening method by which a health care provider reviews a procedure or hospital admission performed by a colleague to assess its necessity
Continuum of care - CORRECT ANSWER Clinical services provided during a single inpatient hospitalization, or for mutliple condition over a lifetime. It provides a basis for evaluating quality , costs, and utilization over the long term
Co-payment or Co-pays - CORRECT ANSWER A nominal, out of pocket fee paid by the patient. It is a fee to help offset paperwork and other administrative costs for each office visit, prescripiotn filled or diagnositc test. Today, nearly all health plans have implemented multi-tiered co-pays particualry for pharmacy benefits. In managed care plans, the member pays the copayment while checkin in for his or her appointment. Services subject to a copayment are not subject to deductible and coinusrance. For example, a prescripiton for a generic drug may be associated with only a $ 7.50 copay; a prescripition for a preferred brand name drug my have a $ 15 co-pay and a co-pay for a nonpreferred brand name drug may be $50
Covered Charges - CORRECT ANSWER Charges for medical care and supplies for which the insurance plan will pay
CPT code - CORRECT ANSWER a unique set of 5 digit identifying numerical code that accompanies a list of medical services performed by physicians and other health care providers. CPT codes are developed and maintained by the American Medical
Association. It has become the industry coding standard for reporting.
CPT Modifers - CORRECT ANSWER Additional codes that indicate that a service was altered in some way from the stated CPT description without actually changing the basic definition of the service. Modifiers can indicate: a service or procedure that has both a professional and a technical component; a service or procedure that was preformed by more than one physician; that only part of a service was performed; that an adjunctive service was performed; that a bilateral procedure was preformed; that service or procedure was provided more than once; an unusual event occurred, or a procedure or service was altered in some way. A compete listing of all modifiers used in CPT coding is located in an appendix of CPT
CQI - CORRECT ANSWER an acronym for " continous quality improvment"
Credentialing - CORRECT ANSWER The reviewing of medical degrees, licensure, malpractice and any disciplinary record of medical poroviders to determine if they should be entitled to privileges at a hospital, health system or to contract with a managed cae organIzation. Credentialing is usually preformd for panel and quality assurance purposes
Critical Care - CORRECT ANSWER THE CARE OF CRITCALLY ILL PATIENTS IN A VARIETY OF MEDICAL EMERGENCIES THAT REQUIRES THE CONSTANT ATTENDANCE BY THE PHYSICIAN( CARDIAC ARREST, SHOCK, BLEEDING, RESPIRATORY FAILURE, POSTOPERATIVE COMPLICATIONS, OR CRITICALLY ILL NEONATE
D/C - CORRECT ANSWER An abbreviation used for either " discharge or discontinue
Days per Thousand - CORRECT ANSWER a standard unit of measurement of utiliztion determined by calculating the number of hospital days used in a year of each thousand covered lives
Deductible - CORRECT ANSWER A fixed amount of helath care dollars of which a person must pay 100% before his or her health benefits begin. Most indemnity plans feature a $200 or $1200 deductible, and then pay up to a defined percentage of money spent for covered services above this level
Dependent - CORRECT ANSWER An individual who receives health insurance through a spouse, parent , domestic partner, or other family member
Diagnosis - CORRECT ANSWER The identification of a condition, disease, or syndorme and its implications, via examination
Disallowance - CORRECT ANSWER a denial by a health care payer for portions of the claimed amount. Examples could include coordination of benefits, services that are not covered, or amounts over the fee maximum
Discharge plan - CORRECT ANSWER a plan submitted by a provider to the case manager as part of the treatment arrangement that details follow-up care after discharge
Disenrollment - CORRECT ANSWER The procedure of dismissing individuals or groups from their enrollment with a health care carrier
DME - CORRECT ANSWER an acronym for " durable medical equipment" which includes permanent equipment meant to be used for medical treatment
DOS - CORRECT ANSWER An acronym for " date of service" refers to the date on which the care was provided
DRG - CORRECT ANSWER An acronym for " diagnosis related group"; refers to a statistical system of classifying any inpatient stays into groups, for purposes of payment. DRGs may be primary or secondary, and an outlier classification also exists. It is also the form of reimbursement that the Centers of Medicare and Medicaid services ( CMS )uses to pay hopsitals for medicare patients. They are also used by a few states for all payers and by some private health plans for contracting purposes.
Drug Addiction - CORRECT ANSWER Mental and/or physical dependence on drugs other than alcohol due to chronic and habitual use
EAP - CORRECT ANSWER An acronym for "employee assitance program" refers to employer provided, short-term counsleing that is offered to members to quickly resolve transient emotional problems and to identify on-going mental or substance abuse problems for susequent referral. EAPS are often limited to a handful of visits.
Economic Waste - CORRECT ANSWER any intervention for which the value of expected benefit is less than the expected costs. More common than medical waste b/c of third party payment
EDI - CORRECT ANSWER An acronym for " electronic dat interchange" EDI refers to the electronic transference of information such as claims, certifications, quality assurance reviews, and utiliztion data
Eligible Dependent - CORRECT ANSWER a dependent of a covered employee who meets the requirments specified in the group contract to qualify for coverage
Eligible Employee - CORRECT ANSWER an employee who meets the eligibility requirment specified in the gorup contract to qualify for coverage
ELOS - CORRECT ANSWER An acronym for " estimated length of stay"; refers to the average number of days of hospitalization required for a given illness or procedure. It is based on prior histories of patients who have been hospitalIzed for the same illness or procedure.
Emergnecy Medical Treatment - CORRECT ANSWER Treatment of patients in emergency medical situations; includes the treatment , care, services or supplies furnished or required to screen for evaluate, and treat a patient until they are stabilized.
Emergicenter - CORRECT ANSWER A health care facility, the primary purpose of which is the provision of immediate, short-term medical care for urgent medical conditions
Employee Contribution - CORRECT ANSWER The portion of the insurance premium paid by the employee
Enrollee - CORRECT ANSWER The person who subscribes to a specific health plan
EOB - CORRECT ANSWER an acronym for " explanation of benefits" It is a statement mailed to the health plan or insured member( and sometimes provider) explaining claim and payment
Episode of Care - CORRECT ANSWER All treatments rendered in a specifed time frame for a specific disease
EPO - CORRECT ANSWER An abbreviation for Exclusive Provider OrganIzation, An EPO is a form of preferred provider organization of PPO, in which patients must visit a caregiver that is on its panel of providers. If a visit to an outside provider is made, the EPO will offer limited or no coverage for the office/hospital visit.
ERISA - CORRECT ANSWER An aronym for Employee Retirment income Security ACt. This act has several provisions protecting both the payer and member, including requiring that payers send the member an EOB when a claim is denied
Exclusions - CORRECT ANSWER Also referred to as exceptions; refers to services or drugs not covered by the health plan/insurance
Experimental drugs - CORRECT ANSWER Drugs that are still being investigated. They are not yet approved by the Food and Drug administration ( FDA) for any use. Additionally, there is not enough accumulated scientific data to establish medically appropriate use of the drug for treatment of a disease. However, the FDA has established programs to allow patients with an immediately life-threatening disease " early access" to new treatments. Since patients who have exhausted standard therapeutic options may be willing to accept additional risks and potentially dangerous side effects from drug products still under study, these programs allow patients access to invesigational drugs. Experimental/investigational drugs are usally excluded benefits in managed care organizations and therefore are not covered for enrollees.
Extended care Facility - CORRECT ANSWER A nursing home or other long-term setting that offers skilled, intermediate, or cusodial care.
Extension of benefits - CORRECT ANSWER A component of some health care insurance ploicies that allows medical coverage to continue past the termination date of the policy for employees not activley at work
FDA - CORRECT ANSWER Anacronym for the United States ( US) Food and Drug Adminstration
Fee-for-services( FFS) - CORRECT ANSWER traditional provider reimbursement in which the physician is paid according to the service performed. this is the reimbursment system used by conventional indemnity insurers
Fee schedule - CORRECT ANSWER The maximum fees a plan will pay for servies, primarly listed by CPT code
Fee-for-services( FFS) - CORRECT ANSWER this is the reimbursment system used by conventional indemnity insurers
Formulary - CORRECT ANSWER A specific list of drugs that are covered within a given health paln ( MCO) , health system or hopsital which may be used in patients that are being cared for in that particualr setting. The list is continually updated as new information about medications becomes available. When drugs are reviewed for formulary inclusion, efficacy and safety are considered first, follwed by cost. If, however, the safety and efficacy are the same for agents being reviewed, cost may be considered first. the formulary usually includes other information on related products and information, representing the clinical judgement of physicians, pharmacists, and other experts in the diagnosis and/or treatment of disease and health promotion. The most common types of formularies are closed and open formulary. They may also be referred to as a preferred drug list
freestanding Outpatient Surgical Center - CORRECT ANSWER A healthcare facility, that is physically separate from a hospital, which provides pre-scheduled outpatient surgical services. It may also be called a surgicenter.
Gate Keeper - CORRECT ANSWER a practice in which a member's care must be provided by a primary care physician ( PCP), unless the physician refers the memnber to a specialist or approves the care porvided by a specialist. Many health Maintenance Organizations ( HMOs) rely on the PCP to be th "gatekeeper". This health care provider screens patients seeking medical care and effectively eliminates costly and sometimes needless specialty referrals for diagnosis and managment. The gatekeeper is responsible for administration of the patient's treatment and must coordinate and obtain authoriation for all medical service's laboratory studies, specialty referrals, and hopspitalizations. In most HMOs if an enrollee visits a specialist without piror authorization from his or her designated PCP, the enrollee must pay for medical services. Sometimes enrollees have plans that do not require specialist referral; in these cases the enrollee would not be subject to " gatekeeping" by their PCP.
Generic Drug - CORRECT ANSWER A prescription drug which is known by its common name reather than a brand or branded name. Its active ingredient is equivalent to its brand name counterpart. By law, generic durgs must meet the same standards for safety, purity, strength, and effectiveness as brand name drug. Generic drugs are a chemically equivalent copy of the brand name drug whose patent has expired and they are typically less expensive [Show Less]