CCM Practice Exam 2026/2027 | Latest Exam Questions & Answers | Fully
Solved with Detailed Rationales | Graded A+
All of the following are true regarding coordination of benefits (COB) except:
A) COB prevents double payment for services when a subscriber has health insurance coverage from
two or more sources.
B) COB is voluntary.
C) COB determines which insurer pays first when the insured is covered under more than one health
insurance policy.
D) COB coordinates workers' compensation with health insurance coverage. - ANSWER ANSWER: D)
COB coordinates workers' compensation with health insurance coverage.
Rationale: COB does not coordinate benefits with workers compensation. COB is a voluntary program
that prevents double payment for services when the subscriber has health insurance from more than
one source. COB has rules to determine which insurer pays first.
Utilization management reviews services to ensure that:
A) each line item on a submitted claim is an appropriate charge
B) they are medically necessary, provided in the most appropriate care setting, and at or above
quality standards.
C) appropriate discharge planning is performed.
D) they are ordered by a physician, provided in the most appropriate care setting, and exceed quality
standards. - ANSWER ANSWER: B) they are medically necessary, provided in the most appropriate
care setting, and at or above quality standards.
Resource: CCMC Glossary of Terms
Rationale: Utilization Management: Review of services to ensure that they are medically necessary,
provided in the most appropriate care setting, and at or above quality standards.
The case managers role when working with clients with substance abuse is to:
A) Motivate the client to change.
B) Support the treatment plan and assist in finding resources.
C) Counsel the client.
, D) Monitor for substance use. - ANSWER ANSWER: B) Support the treatment plan and assist in
finding resources.
To meet the criteria of medical necessity all of the following should be present except:
A) It is reasonable
B) It is based on evidence-based standards of care
C) It is appropriate
D) It is custodial - ANSWER ANSWER: D) It is custodial
The Ambulatory Payment Classification System (APC) is used to determine payment rates for which
one of the following under Medicare?
A) Ambulatory surgery
B) Outpatient rehabilitation and ambulatory surgery
C) ER, hospital-based clinic, observation, and ambulatory surgery
D) Physician office visits - ANSWER ANSWER: C) ER, hospital-based clinic, observation and
ambulatory surgery
Rationale: The Ambulatory Payment Classification System (APC) is Medicare's prospective payment
system for the hospital-based clinic, ER, observation, and ambulatory surgery encounter.
Which would be most appropriate for a 48-year-old nurse who has a broken leg as the result of a
work-related injury?
A) Work hardening
B) Work adjustment
C) Transitional Work Duty
D) Temporary Total Disability - ANSWER ANSWER: C) Transitional Work Duty
Rationale: Transitional work duty (TWD) allow an injured employee to return to work. The employer
will create a temporary position which conforms to the restrictions put in place by the employee's
treating physician.
Which of the following is not used by case managers to foster wellness and autonomy?
A) Advocacy
Solved with Detailed Rationales | Graded A+
All of the following are true regarding coordination of benefits (COB) except:
A) COB prevents double payment for services when a subscriber has health insurance coverage from
two or more sources.
B) COB is voluntary.
C) COB determines which insurer pays first when the insured is covered under more than one health
insurance policy.
D) COB coordinates workers' compensation with health insurance coverage. - ANSWER ANSWER: D)
COB coordinates workers' compensation with health insurance coverage.
Rationale: COB does not coordinate benefits with workers compensation. COB is a voluntary program
that prevents double payment for services when the subscriber has health insurance from more than
one source. COB has rules to determine which insurer pays first.
Utilization management reviews services to ensure that:
A) each line item on a submitted claim is an appropriate charge
B) they are medically necessary, provided in the most appropriate care setting, and at or above
quality standards.
C) appropriate discharge planning is performed.
D) they are ordered by a physician, provided in the most appropriate care setting, and exceed quality
standards. - ANSWER ANSWER: B) they are medically necessary, provided in the most appropriate
care setting, and at or above quality standards.
Resource: CCMC Glossary of Terms
Rationale: Utilization Management: Review of services to ensure that they are medically necessary,
provided in the most appropriate care setting, and at or above quality standards.
The case managers role when working with clients with substance abuse is to:
A) Motivate the client to change.
B) Support the treatment plan and assist in finding resources.
C) Counsel the client.
, D) Monitor for substance use. - ANSWER ANSWER: B) Support the treatment plan and assist in
finding resources.
To meet the criteria of medical necessity all of the following should be present except:
A) It is reasonable
B) It is based on evidence-based standards of care
C) It is appropriate
D) It is custodial - ANSWER ANSWER: D) It is custodial
The Ambulatory Payment Classification System (APC) is used to determine payment rates for which
one of the following under Medicare?
A) Ambulatory surgery
B) Outpatient rehabilitation and ambulatory surgery
C) ER, hospital-based clinic, observation, and ambulatory surgery
D) Physician office visits - ANSWER ANSWER: C) ER, hospital-based clinic, observation and
ambulatory surgery
Rationale: The Ambulatory Payment Classification System (APC) is Medicare's prospective payment
system for the hospital-based clinic, ER, observation, and ambulatory surgery encounter.
Which would be most appropriate for a 48-year-old nurse who has a broken leg as the result of a
work-related injury?
A) Work hardening
B) Work adjustment
C) Transitional Work Duty
D) Temporary Total Disability - ANSWER ANSWER: C) Transitional Work Duty
Rationale: Transitional work duty (TWD) allow an injured employee to return to work. The employer
will create a temporary position which conforms to the restrictions put in place by the employee's
treating physician.
Which of the following is not used by case managers to foster wellness and autonomy?
A) Advocacy
