CCM PRACTICE TIPS EXAM QUESTIONS AND ANSWERS
RATED A+
✔✔Dependent - ✔✔An individual who receives health insurance through a spouse,
parent , domestic partner, or other family member
✔✔Diagnosis - ✔✔The identification of a condition, disease, or syndorme and its
implications, via examination
✔✔Disallowance - ✔✔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 - ✔✔a plan submitted by a provider to the case manager as part of
the treatment arrangement that details follow-up care after discharge
✔✔Disenrollment - ✔✔The procedure of dismissing individuals or groups from their
enrollment with a health care carrier
✔✔DME - ✔✔an acronym for " durable medical equipment" which includes permanent
equipment meant to be used for medical treatment
✔✔DOS - ✔✔An acronym for " date of service" refers to the date on which the care was
provided
✔✔DRG - ✔✔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 - ✔✔Mental and/or physical dependence on drugs other than alcohol
due to chronic and habitual use
✔✔EAP - ✔✔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 - ✔✔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 - ✔✔An acronym for "electronic data interchange" EDI refers to the electronic
transference of information such as claims, certifications, quality assurance reviews,
and utilization data
✔✔Eligible Dependent - ✔✔a dependent of a covered employee who meets the
requirments specified in the group contract to qualify for coverage
✔✔Eligible Employee - ✔✔an employee who meets the eligibility requirment specified in
the group contract to qualify for coverage
✔✔ELOS - ✔✔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 - ✔✔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 - ✔✔A health care facility, the primary purpose of which is the
provision of immediate, short-term medical care for urgent medical conditions
✔✔Employee Contribution - ✔✔The portion of the insurance premium paid by the
employee
✔✔Enrollee - ✔✔The person who subscribes to a specific health plan
✔✔EOB - ✔✔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 - ✔✔All treatments rendered in a specifed time frame for a specific
disease
✔✔EPO - ✔✔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 - ✔✔An acronym for Employee Retirement 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 - ✔✔Also referred to as exceptions; refers to services or drugs not
covered by the health plan/insurance
,✔✔Experimental drugs - ✔✔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 - ✔✔A nursing home or other long-term setting that offers
skilled, intermediate, or cusodial care.
✔✔Extension of benefits - ✔✔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 - ✔✔Anacronym for the United States ( US) Food and Drug Adminstration
✔✔Fee-for-services( FFS) - ✔✔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 - ✔✔The maximum fees a plan will pay for servies, primarly listed by
CPT code
✔✔Fee-for-services( FFS) - ✔✔this is the reimbursment system used by conventional
indemnity insurers
✔✔Formulary - ✔✔A specific list of drugs that are covered within a given health plan (
MCO) , health system or hospital which may be used in patients that are being cared for
in that particular 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 - ✔✔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 - ✔✔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 - ✔✔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.
✔✔Grace Period - ✔✔the period of time after a member has terminated employment,
for which he or she is still covered.
✔✔GxT - ✔✔an abbreviation which stand for " graded exercise test"
✔✔Handoff - ✔✔A type of care transition. Typically refers to a patient changing
providers or settings within one level of care. Includes a temporary transfer of care,
such as from inpatient, clinic, or ED or to OR, porcedure area, or diagnostic area; can
also include a change in provider or change in service, such as nursing staff shift
change, resident sign-outs, or house staff rotation change.
✔✔handover - ✔✔another name for handoff
✔✔HCFA - ✔✔an acronym for Health care Financing Administration, which is now
known as CMS. This is the federal agency that oversees all of the money for Medicare.
✔✔HCPCS - ✔✔An acronym for the HCFA's common procedural coding system. They
are codes used by medicare and other payers to describe products, procedures and
supplies
✔✔HCPCS Modifiers - ✔✔Modifiers should, or in some cases must, be used to idenify
circumstances that alter or enhance the description of a service or supply. They are
recognized by carriers nationally and are updated annually by CMS. Level II/Local
modiferes are assigned by individual Medicare carriers and are distributed to physicians
RATED A+
✔✔Dependent - ✔✔An individual who receives health insurance through a spouse,
parent , domestic partner, or other family member
✔✔Diagnosis - ✔✔The identification of a condition, disease, or syndorme and its
implications, via examination
✔✔Disallowance - ✔✔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 - ✔✔a plan submitted by a provider to the case manager as part of
the treatment arrangement that details follow-up care after discharge
✔✔Disenrollment - ✔✔The procedure of dismissing individuals or groups from their
enrollment with a health care carrier
✔✔DME - ✔✔an acronym for " durable medical equipment" which includes permanent
equipment meant to be used for medical treatment
✔✔DOS - ✔✔An acronym for " date of service" refers to the date on which the care was
provided
✔✔DRG - ✔✔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 - ✔✔Mental and/or physical dependence on drugs other than alcohol
due to chronic and habitual use
✔✔EAP - ✔✔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 - ✔✔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 - ✔✔An acronym for "electronic data interchange" EDI refers to the electronic
transference of information such as claims, certifications, quality assurance reviews,
and utilization data
✔✔Eligible Dependent - ✔✔a dependent of a covered employee who meets the
requirments specified in the group contract to qualify for coverage
✔✔Eligible Employee - ✔✔an employee who meets the eligibility requirment specified in
the group contract to qualify for coverage
✔✔ELOS - ✔✔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 - ✔✔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 - ✔✔A health care facility, the primary purpose of which is the
provision of immediate, short-term medical care for urgent medical conditions
✔✔Employee Contribution - ✔✔The portion of the insurance premium paid by the
employee
✔✔Enrollee - ✔✔The person who subscribes to a specific health plan
✔✔EOB - ✔✔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 - ✔✔All treatments rendered in a specifed time frame for a specific
disease
✔✔EPO - ✔✔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 - ✔✔An acronym for Employee Retirement 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 - ✔✔Also referred to as exceptions; refers to services or drugs not
covered by the health plan/insurance
,✔✔Experimental drugs - ✔✔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 - ✔✔A nursing home or other long-term setting that offers
skilled, intermediate, or cusodial care.
✔✔Extension of benefits - ✔✔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 - ✔✔Anacronym for the United States ( US) Food and Drug Adminstration
✔✔Fee-for-services( FFS) - ✔✔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 - ✔✔The maximum fees a plan will pay for servies, primarly listed by
CPT code
✔✔Fee-for-services( FFS) - ✔✔this is the reimbursment system used by conventional
indemnity insurers
✔✔Formulary - ✔✔A specific list of drugs that are covered within a given health plan (
MCO) , health system or hospital which may be used in patients that are being cared for
in that particular 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 - ✔✔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 - ✔✔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 - ✔✔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.
✔✔Grace Period - ✔✔the period of time after a member has terminated employment,
for which he or she is still covered.
✔✔GxT - ✔✔an abbreviation which stand for " graded exercise test"
✔✔Handoff - ✔✔A type of care transition. Typically refers to a patient changing
providers or settings within one level of care. Includes a temporary transfer of care,
such as from inpatient, clinic, or ED or to OR, porcedure area, or diagnostic area; can
also include a change in provider or change in service, such as nursing staff shift
change, resident sign-outs, or house staff rotation change.
✔✔handover - ✔✔another name for handoff
✔✔HCFA - ✔✔an acronym for Health care Financing Administration, which is now
known as CMS. This is the federal agency that oversees all of the money for Medicare.
✔✔HCPCS - ✔✔An acronym for the HCFA's common procedural coding system. They
are codes used by medicare and other payers to describe products, procedures and
supplies
✔✔HCPCS Modifiers - ✔✔Modifiers should, or in some cases must, be used to idenify
circumstances that alter or enhance the description of a service or supply. They are
recognized by carriers nationally and are updated annually by CMS. Level II/Local
modiferes are assigned by individual Medicare carriers and are distributed to physicians
