CCM Glossary Exam 115 Questions with Verified Answers
AAPM&R - CORRECT ANSWER American Academy of Physical Medicine and Rehabilitation
Access to
... [Show More] care - CORRECT ANSWER the ability and ease of clients to obtain healthcare when they need it
Accessible - CORRECT ANSWER a term used to denote building facilities that are barrier-free thus enabling all members of society safe access, including persons with physical disabilities.
Accountable Care Organization (ACO) - CORRECT ANSWER A set of healthcare providers including primary care physicians, specialists, and hospitals that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a population of patients.
Accreditation - CORRECT ANSWER A standardized program for evaluating healthcare organizations to ensure a specified level of quality, as defined by a set of national industry standards.
Actionable tort - CORRECT ANSWER A legal duty, imposed by statute or otherwise, owing by defendant to the one injured
Active listening - CORRECT ANSWER A structured way of communication and interacting in which one is engaged with the speaker primarily through focused attention and suspension of one's own frame of reference, biases, distractions, and judgment.
Activities of Daily Living - CORRECT ANSWER Routine activities an individual tends to de every day for self-care and normal living. These include eating, bathing, grooming, dressing, toileting, transferring and continence.
Activity limitations - CORRECT ANSWER Difficulties an individual may have in executing activities. These may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition.
Actual value is also referred to as - CORRECT ANSWER Real value is also referred to as
Actual value - CORRECT ANSWER Measures the worth one derives from using or consuming a good, product, service or an item, and represents the utility of the good, product, service, or item.
Actuarial study - CORRECT ANSWER Statistical analysis of a population based on its utilization of healthcare services and demographic trends of teh population. Results used to estimate healthcare plan premiums or costs.
Actuary - CORRECT ANSWER A trained insurance professional who specializes in determining policy rates, calculating premiums, and conducting statistical studies.
Acuity - CORRECT ANSWER Complexity and severity of the client's health/medical condition
Acute care - CORRECT ANSWER Focuses on treating sudden and ___________ episodes of illness such as medical and surgical management or emergency treatment which otherwise cannot be taken care of in a less intense care setting.
ADA - CORRECT ANSWER Americans with Disabilities Act of 1990
ADAAA - CORRECT ANSWER Americans with Disabilities Ammendments Act of 2008
Adaptive behavior - CORRECT ANSWER The effectiveness and degree to which an individual meets standards of self-sufficiency and social responsibility for his/her age-related cultural group
Adherence - CORRECT ANSWER The extent to which a person's behavior--taking medication, following a dieth, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider.
Adhesive contract - CORRECT ANSWER An agreement between two parties where one party with stronger bargaining power sets the terms and conditions and the other party, which is the weaker of the two with little to no ability to negotiate, must adhere to the contract and is placed in a "take it or leave it" position.
Adjusted Clinical Group (ACG) System - CORRECT ANSWER The system clusters clients into homogenous groups based on a unique approcach to measuring morbidity to ultimately improve accuracy and fairness in evaluating healthcare provider performance, identifying clients at high risk, forecasting healthcare utilization, and setting equitable payment structure and rates for the providers of care.
Adjuster - CORRECT ANSWER A person who handles claims
Administrative law - CORRECT ANSWER That branch of public laws that deals with the various organizations of federal, state, and local governments which prescribes in detail the manner of their activities.
Administrative Services Only (ASO) - CORRECT ANSWER An insurance company or third-party administrator that delivers administrative services to an employer group. This usually requires the employer to be at risk for the cost of healthcare services provided.
Admission certification - CORRECT ANSWER A form of utilization review in which an assessment is made of the medical necessity of a client's admission to a hospital or other inpatient facility. It ensures taht clients requiring a hospital-based level of care and length of stay appropriate for the admission diagnosis are usually assigned and certified and payment for teh services are approved.
Admission review - CORRECT ANSWER A review that occurs within 24 hours of a client's admission to a healthcare facility or according to the time frame required in the contractual agreement between healthcare provider and the health insurance plan.
Advance directive - CORRECT ANSWER Legally executed document that explains the client's healthcare related wishes and decisions. It is drawn up while the client is still competent and is used if the client becomes incapacitated or incompetent.
Adverse events - CORRECT ANSWER Any untoward occurrences, which under most conditions are not natural consequences of the client's disease process or treatment outcomes.
Advocacy - CORRECT ANSWER The act of recommending, pleading the cause of another; to speak or write in favor of.
Advocate - CORRECT ANSWER A person or agnecy who speaks on behalf of others and promotes their causes.
Affect - CORRECT ANSWER The observable emotional condition of an individual at any given time.
Affidavit - CORRECT ANSWER A written statement of fact signed and sworn before a person authorized to administer an oath.
Aggregated Diagnosis Groups (ADGs) - CORRECT ANSWER A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a client's health condition over time.
Agreed medical examination - CORRECT ANSWER An evaluation conducted by a provider who is selected by agreement between an injured workers' attorney and the insurance claims administrator and/or attorney. The evaluation serves to determine what portions of the work-related injury have contributed to the disability and what portions have resulted from other sources of causation.
AHA - CORRECT ANSWER American Heart Association
AHRQ - CORRECT ANSWER Agency for Healthcare Research and Quality
Algorithm - CORRECT ANSWER The chronological delineation of the steps in, or activities of, client care to be applied in the care of clients as they relate to specific conditions/situations.
Alternate level of care - CORRECT ANSWER A level of care that can safely be used in place of the current level and determined based on the acuity and complexity of the client's condition and the type of needed services and resources
AMA - CORRECT ANSWER American Medical Association
Ambulatory Payment Classification (APC) System - CORRECT ANSWER An encounter-based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and ambulatory surgery. Payment rates are based on categories of services that are similar in cost and resource utilization.
ANA - CORRECT ANSWER American Nurses Association
ANCC - CORRECT ANSWER American Nurses Credentialing Center
Ancillary services - CORRECT ANSWER Other diagnostic and therapeutic services that may be involved in the care of clients other than nursing or medicine. Includes respiratory, laboratory, radiology, nutrition, physical and occupational therapy, and pastoral services.
Appeal (Care provision related) - CORRECT ANSWER The formal process or request to reconsider a decision made not to approve an admission or healthcare services, reimbursement for services rendered, or a client's request for postponing the discharge date and extending the length of stay.
Appeal (legal in nature) - CORRECT ANSWER The process whereby a court of appeals reviews the record of written materials from a trail court proceeding to determine if errors were made that might lead to a reversal of the trial court's decision.
Appropriateness of setting - CORRECT ANSWER Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible.
Approval - CORRECT ANSWER In the area of health insurance, it is the act of authorizing or affirmng a service to a client that implies agreement to be responsible for reimbursing the provider of the service the related cost of providing the service to a client/support system.
Approved charge - CORRECT ANSWER The amount Medicare pays a physician based on the Medicare fee schedule. Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.
Assessment - CORRECT ANSWER The process of collecting in-depth information about a person's situation and functioning to idetify individual needs in order to develop a comprehensive case management plan that will address those needs.
Assignment of benefits - CORRECT ANSWER Paying medical benefits directly to a provider of care rather than to a member.
Assistive device - CORRECT ANSWER Any tool that is designed, made, or adapted to assist a person to perform a particular task.
Assistive technology - CORRECT ANSWER Any item, piece of equipment, or product system, whether acquired commercially or off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.
Assistive technology services - CORRECT ANSWER Any service that directly assists an individual with a disability in the selction, acquisition, or use of an assistive technology device.
Assumption of risk - CORRECT ANSWER A doctrine based upon voluntary exposure to a known risk. It is distinguished from contributory negligence, which is based on carelessness, in that it involves a comprehension that a peril is to be encountered and a willingness to encounter it.
nsurance - CORRECT ANSWER The spreading of risk among many, among whom few are likely to suffer loss.
Authorization - CORRECT ANSWER The approval of client care services, admission, or length of stay by a health benefit plan based on information provided by the healthcare provider.
Autonomy - CORRECT ANSWER Agreement to respect another's right to self-determine a course of action, support of independent decision making.
Bad faith - CORRECT ANSWER Generally involving actual or constructive fraud, or a design to mislead or deceive another.
Barrier-free - CORRECT ANSWER A physical, manmade environment or arrangement of structures that is safe and accessible to persons with disabilities.
Barriers - CORRECT ANSWER Factors in a person's environment that, if absent or present, limit one's functioning and creat disability. THey also include services, systems, and policies that are either nonexistent or that hinder the involvement of people with a health condition in any area of life.
BAS - CORRECT ANSWER Burden Assessment Scale
Benchmarking - CORRECT ANSWER An act of comparing a work process with that of the best competitor. Through this process one is able to identify what performance measure levels must be surpassed. Assists an organization in assessing it's strengths and weaknesses and in finding and implementing best practices.
Beneficence - CORRECT ANSWER Compassion; taking positive action to help others; desire to do good;' core principle of client advocacy
Beneficiary - CORRECT ANSWER An individual eligible for benefits under a particular plan.
Benefit package - CORRECT ANSWER The sum of services for which a health plan, government agency, or employer contracts to provide.
Benefits - CORRECT ANSWER The type of health and human services covered by an insurance company/health plan and as agreed upon between the plan/insurance company and the individual enrollee or participant.
Beyond-the-walls case management - CORRECT ANSWER MOdels where healthcare resources, services, and case managers are based externally to an acute care/hospital setting, that is in the community.
Body of Knowledge (BOK) - CORRECT ANSWER Widely recognized information, standards, methods, tools, and practices about a specific field.
Bona Fide - CORRECT ANSWER In good faith
Brain disorder - CORRECT ANSWER a loosely used term for a neurological disorder or syndrome indicating impairment or injury to brain tissue.
Brain injury - CORRECT ANSWER Any damage to tissues of the brain that leads to impairment of the function of the Central Nervous System
Burden of proof - CORRECT ANSWER THe duty of producing evidence as the case progresses, and/or the duty to establish the truth of the claim by a preponderance of teh evidence. The former may pass from party to party, the latter rest throughout upon the party asserting the affirmative of the issue.
Capacity - CORRECT ANSWER A construct taht indicates the highest probable level of functioning a person may reach
Capitation - CORRECT ANSWER A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services rather than based on specific services provided. The typical reimbursement method used by HMOs.
Captive - CORRECT ANSWER An insurance company formed by an employer to assume its workers' compensation and other risks, and provide services
Care Continuum Alliance - CORRECT ANSWER Previously known as the Disease Management Association of America (DMAA)
Care Coordination - CORRECT ANSWER The deliberate organization of patient care activities between two or more participants involved in patient's care to facilitate the appropriate delivery of health care services.
Care Coordination Hub - CORRECT ANSWER The context of delivering integrated healthcare services to clients/support systems with sepcial emphasis on collaboration, coordination and communication among multiple healthcare providers, care settings, and agencies in an attempt to ensure client's safety and the provision of quality, cost-effective case management services
Care guidelines - CORRECT ANSWER Nationally recognized and professionally supported plans of care recommended for the care management of clients with a specific diagnosis or health condition and in a particular care setting.
Care management - CORRECT ANSWER A healthcare delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly. It also helps avoid unnecessary services by preventing medical problems from escalating.
Care setting/'Practice setting/Level of care - CORRECT ANSWER A place across the continuum of health and human services where a client may receive healthcare services dependent on need. Settings may vary based on intensity and complexity of teh services provided to clients.
Caregiver - CORRECT ANSWER The person responsible for caring for a client in the home setting. Can be a family member, friend, volunteer, or an assigned healthcare professional.
Comission of Accreditation of Rehabilitation Facilities (CARF) - CORRECT ANSWER A private, non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards
Carpal Tunnel Syndrome - CORRECT ANSWER The name given to the symptoms that occur when the nerves and the tendons running through the wrist are compressed by tissue or bone or become irritated and swell.
Carrier - CORRECT ANSWER The insurance company or the one who agrees to pay the losses
Carve out - CORRECT ANSWER Services excluded from a provider contract that may be covered through arrangements with other providers
Case-based review - CORRECT ANSWER The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professionals assigned by the hospital or an outside agency.
Case closure - CORRECT ANSWER Terminating the provision of case management services to a client/support system. The process of cummunicating the decision to terminate services to clients/support systems, payor representative, and other healthcare professional involved
Case conference - CORRECT ANSWER A multidisciplinary healthcare team meeting that is held to discuss a client or client's support system, clarification of plan of care and prognosis, end of life issues, or an ethical dilemma.
Case law - CORRECT ANSWER The aggregate of reported cases forming a body of jurisprudence, or the law of a particular subject as evidenced or formed by the adjudged cases, in distinction to statutes and other sources of law.
Case management - CORRECT ANSWER A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human services needs.
Case management is characterized by.... - CORRECT ANSWER advocacy, communication, and resource managment, and promotes quality and cost-effective interventions and outcomes
Case Management Body of Knowledge (CMBOK) - CORRECT ANSWER A comprehensive resource of essential knowledge in the field of case management taht a case manager is expected to master and become knowledgeable, skilled, as well as experienced in, to effectively care for clients and their support systems and be considered a competent case management practitioner.
Case management department - CORRECT ANSWER A division within a health care organization responsible for the provision of case management services to clients and their support systems
Case management model - CORRECT ANSWER A conceptual or graphic representation of the practice of case management in an organization. It usually depicts the relationships among the key functions and stakeholders of case management, and the roles and responsibilities of case managers
Care management plan - CORRECT ANSWER A timeline of patient care activities and expected outcomes of care that address teh plan of care of each discipline involved in the care of a particular patient.
Case management plan of care - CORRECT ANSWER A comprehensive plan of care for an individual client that describes the (1) problems, needs and desires determined based upon findings of the client's assessment; (2) strategies such as treatments and interventions to be instituted to address teh problems and needs; and (3) measurable goals including specific outcomes to be achieved to demonstrate resolution of the problems and needs, the timeframe(s) for achieving them, the resources available and to be used to realize the outcomes, and the desires/motivation of the client that may have an impact on the plan.
Case management process - CORRECT ANSWER The context in which case managers provide health and human services to clients and their support systems. The process consists of several setps or sub-processes that are iterative, cyclical and recursive rather than linear in nature and applied until the client's needs and interests are met. The steps include screening, asessing, stratifying risk, planning, implementing, following-up, transitioning, post-transitioning communication, and evaluating outcomes.
Case management program - CORRECT ANSWER An organized approach to the provision of case management services to clients and their support systems.
Case manager - CORRECT ANSWER A healht and human services professional who is responsible for coordinating the overall care, services, and resources delivered to an individual client or a group of clients and their support systems based on the client's health and human services issues, needs and interests
Case Mix Group (CMG) - CORRECT ANSWER Each one has a relative weight taht determines teh base payment rate for inpatient rehabilitation facilities under the Medicare system.
Case Mix Index (CMI) - CORRECT ANSWER The sum of DRG-relative weights of all patients/cases seen during a 1-year period in an organization, divided by the number of cases hospitalized and treated during the same year.
Case Rates - CORRECT ANSWER Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility and professional practitioner fees for care and services.
Case reserve - CORRECT ANSWER The dollar amount stated in a claim file which represents the estimate of the amount unpaid
Caseload - CORRECT ANSWER The total number of clients followed by a case manager at any pint in time
Casualty insurance - CORRECT ANSWER A general class of insurance and worker's compensation insurance
Catastrophic case - CORRECT ANSWER Any medical condition or illness that has heightened medical, social, and financial consequences that responds positively to the control offered through a systematic effort of case management
Catastrophic case management - CORRECT ANSWER Specialized and intricate services reflective of the needs of individuals with complex and life-altering conditions.
Catastrophic Illness - CORRECT ANSWER Any medical condition or illness that has heightened medical, social, and financial consequences and responds positively to the control offered through a systematic effort of case management services
Catastrophic injury - CORRECT ANSWER A serious injury that results in severe and long-term effects on the individual who sustains it, including permanent severe functional disability. Examples are traumatic brain, spine, or spinal cord injury; multiple trauma; and loss of major body parts
CCM - CORRECT ANSWER Certified Case Manager
CCMC - CORRECT ANSWER Commission for Case Manager Certification
Certification - CORRECT ANSWER The approval of client care services, admission, or length of stay by a health benefit plan based on information provided by the healthcare provider
Certified Nurse Life Care Planner (CNLCP) - CORRECT ANSWER A registered professional nurse who holds a board certification. This health professional develops a client-specific lifetime plan of care, while applying the nursing process. The plan employes a comprehensive and evidence-based approach in the estimation of current and future healthcare needs of the client.
Certified Vocational Evaluator (CVE) - CORRECT ANSWER A professional specialized in vocational assessment and rehabilitation who has met the minimum requirements for nationally recognized voluntary certification. [Show Less]