CCM (Certified Case
Manager) WITH CORRECT
ACTUAL QUESTIONS AND
CORRECTLY WELL DEFINED
ANSWERS LATEST
ALREADY GRADED A+
(2025/2026)
Domain 1: Care Delivery and Reimbursement Methods (1–30)
1. A case manager is coordinating care for a patient with a traumatic
brain injury who has both Medicare and a supplemental Medigap
policy. Which is the primary payer?
A) Medigap policy
B) Medicare Part A
,C) Workers’ compensation
D) Patient’s savings
Rationale: Medicare is the primary payer when a patient has
traditional Medicare plus Medigap. Medigap pays after Medicare.
2. Which reimbursement model pays a fixed amount per patient per
month regardless of services used?
A) Fee-for-service
B) Capitation
C) Discounted fee-for-service
D) Per diem
Rationale: Capitation is a prospective payment model where
providers receive a set PMPM (per member per month) amount.
3. A patient with end-stage renal disease needs dialysis three times
weekly. The case manager knows that under Medicare, ESRD is
covered under:
A) Medicare Part D
B) Medicare Part A and Part B
C) Medicare Part C only
D) Medicaid only
Rationale: ESRD patients qualify for Medicare Parts A (hospital) and
B (outpatient dialysis) after a waiting period or immediately if
starting home dialysis training.
4. A case manager is reviewing a denial for inpatient admission
based on “lack of medical necessity.” The best initial action is:
A) File a lawsuit
B) Review clinical criteria (e.g., InterQual) and discuss with the
attending physician
C) Ignore the denial
D) Discharge the patient immediately
,Rationale: Denials must be evaluated against evidence-based
criteria; physician input is critical before appealing.
5. Which is an example of a concurrent review activity?
A) Certifying an elective surgery before admission
B) Reviewing a patient’s continued stay on day 3 of admission
C) Auditing records after discharge
D) Credentialing a new physician
Rationale: Concurrent review occurs during an active hospital stay
to assess ongoing need for acute-level care.
6. A patient is covered by a high-deductible health plan (HDHP) with
a health savings account (HSA). The case manager advises the
patient that HSA funds can be used for:
A) Mortgage payments
B) Qualified medical expenses like copays and deductibles
C) Groceries
D) Vacation travel
Rationale: HSAs are tax-advantaged accounts for out-of-pocket
medical expenses only; non-medical withdrawals are penalized.
7. A patient has Medicaid and lives in a state with a managed care
organization (MCO) model. The case manager must:
A) Send claims directly to state Medicaid fee-for-service
B) Coordinate with the MCO for prior authorizations and network
providers
C) Ignore the MCO
D) Bill the patient
Rationale: In MCO states, Medicaid beneficiaries receive services
through contracted plans; case managers work with MCO care
managers.
, 8. Which condition is not covered under Medicare Part D?
A) Insulin
B) Blood pressure medication
C) Benzodiazepines in most standard plans (except certain
exceptions)
D) Statins
Rationale: Historically benzodiazepines were excluded; currently
some plans cover with restrictions, but question tests classic
knowledge of Part D restrictions.
9. A case manager works in a hospital that receives a bundled
payment for joint replacement (episode-of-care model). The goal is:
A) Maximize length of stay
B) Coordinate care across settings to reduce costs while maintaining
quality
C) Avoid post-acute care at all costs
D) Bill each service separately
*Rationale: Bundled payments incentivize efficient, coordinated care
across the episode (e.g., 90 days post-op).*
10. A patient is eligible for both Medicare and Medicaid (dual
eligible). The case manager should consider:
A) Medicare always pays last
B) Medicare is primary; Medicaid may cover copays, premiums, and
non-Medicare services
C) Only Medicaid applies
D) Patient must choose one
Rationale: Medicare is primary; Medicaid wraps around for
additional coverage.
11. Which is a defining feature of a Patient-Centered Medical Home
(PCMH) ?
Manager) WITH CORRECT
ACTUAL QUESTIONS AND
CORRECTLY WELL DEFINED
ANSWERS LATEST
ALREADY GRADED A+
(2025/2026)
Domain 1: Care Delivery and Reimbursement Methods (1–30)
1. A case manager is coordinating care for a patient with a traumatic
brain injury who has both Medicare and a supplemental Medigap
policy. Which is the primary payer?
A) Medigap policy
B) Medicare Part A
,C) Workers’ compensation
D) Patient’s savings
Rationale: Medicare is the primary payer when a patient has
traditional Medicare plus Medigap. Medigap pays after Medicare.
2. Which reimbursement model pays a fixed amount per patient per
month regardless of services used?
A) Fee-for-service
B) Capitation
C) Discounted fee-for-service
D) Per diem
Rationale: Capitation is a prospective payment model where
providers receive a set PMPM (per member per month) amount.
3. A patient with end-stage renal disease needs dialysis three times
weekly. The case manager knows that under Medicare, ESRD is
covered under:
A) Medicare Part D
B) Medicare Part A and Part B
C) Medicare Part C only
D) Medicaid only
Rationale: ESRD patients qualify for Medicare Parts A (hospital) and
B (outpatient dialysis) after a waiting period or immediately if
starting home dialysis training.
4. A case manager is reviewing a denial for inpatient admission
based on “lack of medical necessity.” The best initial action is:
A) File a lawsuit
B) Review clinical criteria (e.g., InterQual) and discuss with the
attending physician
C) Ignore the denial
D) Discharge the patient immediately
,Rationale: Denials must be evaluated against evidence-based
criteria; physician input is critical before appealing.
5. Which is an example of a concurrent review activity?
A) Certifying an elective surgery before admission
B) Reviewing a patient’s continued stay on day 3 of admission
C) Auditing records after discharge
D) Credentialing a new physician
Rationale: Concurrent review occurs during an active hospital stay
to assess ongoing need for acute-level care.
6. A patient is covered by a high-deductible health plan (HDHP) with
a health savings account (HSA). The case manager advises the
patient that HSA funds can be used for:
A) Mortgage payments
B) Qualified medical expenses like copays and deductibles
C) Groceries
D) Vacation travel
Rationale: HSAs are tax-advantaged accounts for out-of-pocket
medical expenses only; non-medical withdrawals are penalized.
7. A patient has Medicaid and lives in a state with a managed care
organization (MCO) model. The case manager must:
A) Send claims directly to state Medicaid fee-for-service
B) Coordinate with the MCO for prior authorizations and network
providers
C) Ignore the MCO
D) Bill the patient
Rationale: In MCO states, Medicaid beneficiaries receive services
through contracted plans; case managers work with MCO care
managers.
, 8. Which condition is not covered under Medicare Part D?
A) Insulin
B) Blood pressure medication
C) Benzodiazepines in most standard plans (except certain
exceptions)
D) Statins
Rationale: Historically benzodiazepines were excluded; currently
some plans cover with restrictions, but question tests classic
knowledge of Part D restrictions.
9. A case manager works in a hospital that receives a bundled
payment for joint replacement (episode-of-care model). The goal is:
A) Maximize length of stay
B) Coordinate care across settings to reduce costs while maintaining
quality
C) Avoid post-acute care at all costs
D) Bill each service separately
*Rationale: Bundled payments incentivize efficient, coordinated care
across the episode (e.g., 90 days post-op).*
10. A patient is eligible for both Medicare and Medicaid (dual
eligible). The case manager should consider:
A) Medicare always pays last
B) Medicare is primary; Medicaid may cover copays, premiums, and
non-Medicare services
C) Only Medicaid applies
D) Patient must choose one
Rationale: Medicare is primary; Medicaid wraps around for
additional coverage.
11. Which is a defining feature of a Patient-Centered Medical Home
(PCMH) ?
