CCM EXAM WITH COMPLETE SOLUTIONS 100%
2023/2024
Accountable Care Organization (ACO)
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.
Actionable tort
A legal duty, imposed by statute or otherwise, owing by defendant to the one injured
Actual value is also referred to as
Real value is also referred to as
Actual value
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
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.
Adhesive contract
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
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.
Administrative Services Only (ASO)
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
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
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.
, Adverse events
Any untoward occurrences, which under most conditions are not natural consequences of the client's
disease process or treatment outcomes.
Aggregated Diagnosis Groups (ADGs)
A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a
client's health condition over time.
AHRQ
Agency for Healthcare Research and Quality
Ambulatory Payment Classification (APC) System
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.
Bad faith
Generally involving actual or constructive fraud, or a design to mislead or deceive another.
Beneficence
Compassion; taking positive action to help others; desire to do good;' core principle of client advocacy
Beyond-the-walls case management
MOdels where healthcare resources, services, and case managers are based externally to an acute
care/hospital setting, that is in the community.
Capitation
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.
Care Coordination
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
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
Carve out
Services excluded from a provider contract that may be covered through arrangements with other
providers
2023/2024
Accountable Care Organization (ACO)
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.
Actionable tort
A legal duty, imposed by statute or otherwise, owing by defendant to the one injured
Actual value is also referred to as
Real value is also referred to as
Actual value
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
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.
Adhesive contract
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
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.
Administrative Services Only (ASO)
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
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
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.
, Adverse events
Any untoward occurrences, which under most conditions are not natural consequences of the client's
disease process or treatment outcomes.
Aggregated Diagnosis Groups (ADGs)
A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a
client's health condition over time.
AHRQ
Agency for Healthcare Research and Quality
Ambulatory Payment Classification (APC) System
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.
Bad faith
Generally involving actual or constructive fraud, or a design to mislead or deceive another.
Beneficence
Compassion; taking positive action to help others; desire to do good;' core principle of client advocacy
Beyond-the-walls case management
MOdels where healthcare resources, services, and case managers are based externally to an acute
care/hospital setting, that is in the community.
Capitation
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.
Care Coordination
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
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
Carve out
Services excluded from a provider contract that may be covered through arrangements with other
providers
