CCM LATEST 2026 EXAM QUESTIONS AND ANSWERS
RATED A+
✔✔Case rate - ✔✔rate of reimbursement that packages pricing for a certain category of
services.
✔✔Catastrophic case - ✔✔case with complexities, multiple providers, and services that
will be costly to patient and providers
✔✔Claims - ✔✔request for payment or reparation for a loss covered by insurance
contract.
✔✔Clinical pathways - ✔✔a timeline of patient care activities and expected outcomes of
care.
✔✔Coinsurance - ✔✔a provision under which both the insured and the insurer share
the covered losses, cost-sharing
✔✔Competence - ✔✔the ability to do something successfully or efficiently, mental
capacity
✔✔Concurrent review - ✔✔method of reviewing patient care and services during a
hospital stay to validate care necessity
✔✔Comorbidity - ✔✔the co-occurrence of two or more disorders in a single individual
✔✔Continuous Quality Improvement - ✔✔CQI, process of ongoing review to improve
quality of healthcare services
✔✔Coordination of benefits (COB) - ✔✔process to prevent duplication of payments
when subscriber has coverage from multiple sources
✔✔Copayment - ✔✔a fixed fee paid by the patient at the time of service, example office
visit or prescription
✔✔Credentialing - ✔✔ensures competence of practitioners, process to approve
providers
✔✔Cultural competence - ✔✔behaviors, attitudes, and policies that come together on a
continuum to work in a diverse setting
✔✔custodial care - ✔✔care provided primarily to assist patient in meeting activities of
daily living, don't require Skilled nursing care
,✔✔Current Procedural Terminology - ✔✔A comprehensive list of codes used by
physicians to bill for procedures and services
✔✔Deductible - ✔✔amount of expenses that must be paid out of pocket before an
insurers payments begin
✔✔Denial - ✔✔claim denied due to inability to justify services medically necessary
✔✔Diagnostic related groups, DRG - ✔✔Fixed fee based on diagnosis, give information
about illness pre-set rate they allow
✔✔Disability - ✔✔any lost, absent, or impaired physical or mental function
✔✔Disability income insurance - ✔✔Provides payments to replace income when an
insured person is unable to work
✔✔Eligibility - ✔✔the qualify factor or factors that must be met before a pt receives
benefits
✔✔Ergonomics - ✔✔The study of how the body works in order to design better tools
✔✔Creditable coverage - ✔✔references the time during which a person is covered by
health insurance
✔✔Break in coverage - ✔✔63 days or more without health insurance
✔✔Exclusive provider organization (EPO) - ✔✔a managed care plan that provides
benefits for care given only by network providers
✔✔Fee-for-service (FFS) - ✔✔an insurance payment system where providers are paid
for each service, also called indemnity plan
✔✔Formulary - ✔✔A list of prescription drugs approved by a health plan.
✔✔Functional Capacity Evaluation FCE - ✔✔examination of a worker's physical abilities
to perform required tasks
✔✔Functional job analysis - ✔✔defines the job requirements, both essential and non
essential duties
✔✔Gatekeeper - ✔✔a PCP that manages all referrals for speciality care and other
services
, ✔✔Group Model HMO - ✔✔HMO contracts with a group of physicians to provide
services for a fixed monthly fee per enrollee
✔✔Independent Practice Association (IPA) model - ✔✔a legal entity(private practice)
sponsored by physicians that contracts with HMO : bound by terms of contract
✔✔Network model - ✔✔An organizational arrangement in which an HMO contracts with
more than one medical group practice. A provider network
✔✔Staff Model HMO - ✔✔group of physicians who work and are paid by the HMO and
see only HMO patients
✔✔Handicap - ✔✔condition that interferes with a person's ability to function normally
✔✔Health Insurance - ✔✔Provides money to pay for health care for illness, injury, or in
some cases preventive care.
✔✔Healthcare Maintenance Organization HMO - ✔✔an organization that provides or
arranges for coverage of health services for fixed fee
✔✔Hospice - ✔✔A type of care for terminally ill patients; an organization that provides
such care
✔✔ICD 10 - ✔✔International Classification of Diseases, Tenth Edition, used for coding
MR for reimbursement
✔✔Indemnity Benefits - ✔✔the provider bills the patient for services, insurance
reimburses patient
✔✔Informed Consent - ✔✔consent given by patient, next of kin, legal guardian for
services
✔✔Inpatient Rehabilitation - ✔✔eligibility: tolerate 3 hours of therapy/day, require skilled
service
✔✔Managed care - ✔✔is an approach that has developed in response to rising health
care costs
✔✔Levels of Care - ✔✔the intensity of effort required to diagnose, treat, preserve or
maintain an individuals functional status
✔✔Length of stay - ✔✔The number of days a person stays in a healthcare facility.
RATED A+
✔✔Case rate - ✔✔rate of reimbursement that packages pricing for a certain category of
services.
✔✔Catastrophic case - ✔✔case with complexities, multiple providers, and services that
will be costly to patient and providers
✔✔Claims - ✔✔request for payment or reparation for a loss covered by insurance
contract.
✔✔Clinical pathways - ✔✔a timeline of patient care activities and expected outcomes of
care.
✔✔Coinsurance - ✔✔a provision under which both the insured and the insurer share
the covered losses, cost-sharing
✔✔Competence - ✔✔the ability to do something successfully or efficiently, mental
capacity
✔✔Concurrent review - ✔✔method of reviewing patient care and services during a
hospital stay to validate care necessity
✔✔Comorbidity - ✔✔the co-occurrence of two or more disorders in a single individual
✔✔Continuous Quality Improvement - ✔✔CQI, process of ongoing review to improve
quality of healthcare services
✔✔Coordination of benefits (COB) - ✔✔process to prevent duplication of payments
when subscriber has coverage from multiple sources
✔✔Copayment - ✔✔a fixed fee paid by the patient at the time of service, example office
visit or prescription
✔✔Credentialing - ✔✔ensures competence of practitioners, process to approve
providers
✔✔Cultural competence - ✔✔behaviors, attitudes, and policies that come together on a
continuum to work in a diverse setting
✔✔custodial care - ✔✔care provided primarily to assist patient in meeting activities of
daily living, don't require Skilled nursing care
,✔✔Current Procedural Terminology - ✔✔A comprehensive list of codes used by
physicians to bill for procedures and services
✔✔Deductible - ✔✔amount of expenses that must be paid out of pocket before an
insurers payments begin
✔✔Denial - ✔✔claim denied due to inability to justify services medically necessary
✔✔Diagnostic related groups, DRG - ✔✔Fixed fee based on diagnosis, give information
about illness pre-set rate they allow
✔✔Disability - ✔✔any lost, absent, or impaired physical or mental function
✔✔Disability income insurance - ✔✔Provides payments to replace income when an
insured person is unable to work
✔✔Eligibility - ✔✔the qualify factor or factors that must be met before a pt receives
benefits
✔✔Ergonomics - ✔✔The study of how the body works in order to design better tools
✔✔Creditable coverage - ✔✔references the time during which a person is covered by
health insurance
✔✔Break in coverage - ✔✔63 days or more without health insurance
✔✔Exclusive provider organization (EPO) - ✔✔a managed care plan that provides
benefits for care given only by network providers
✔✔Fee-for-service (FFS) - ✔✔an insurance payment system where providers are paid
for each service, also called indemnity plan
✔✔Formulary - ✔✔A list of prescription drugs approved by a health plan.
✔✔Functional Capacity Evaluation FCE - ✔✔examination of a worker's physical abilities
to perform required tasks
✔✔Functional job analysis - ✔✔defines the job requirements, both essential and non
essential duties
✔✔Gatekeeper - ✔✔a PCP that manages all referrals for speciality care and other
services
, ✔✔Group Model HMO - ✔✔HMO contracts with a group of physicians to provide
services for a fixed monthly fee per enrollee
✔✔Independent Practice Association (IPA) model - ✔✔a legal entity(private practice)
sponsored by physicians that contracts with HMO : bound by terms of contract
✔✔Network model - ✔✔An organizational arrangement in which an HMO contracts with
more than one medical group practice. A provider network
✔✔Staff Model HMO - ✔✔group of physicians who work and are paid by the HMO and
see only HMO patients
✔✔Handicap - ✔✔condition that interferes with a person's ability to function normally
✔✔Health Insurance - ✔✔Provides money to pay for health care for illness, injury, or in
some cases preventive care.
✔✔Healthcare Maintenance Organization HMO - ✔✔an organization that provides or
arranges for coverage of health services for fixed fee
✔✔Hospice - ✔✔A type of care for terminally ill patients; an organization that provides
such care
✔✔ICD 10 - ✔✔International Classification of Diseases, Tenth Edition, used for coding
MR for reimbursement
✔✔Indemnity Benefits - ✔✔the provider bills the patient for services, insurance
reimburses patient
✔✔Informed Consent - ✔✔consent given by patient, next of kin, legal guardian for
services
✔✔Inpatient Rehabilitation - ✔✔eligibility: tolerate 3 hours of therapy/day, require skilled
service
✔✔Managed care - ✔✔is an approach that has developed in response to rising health
care costs
✔✔Levels of Care - ✔✔the intensity of effort required to diagnose, treat, preserve or
maintain an individuals functional status
✔✔Length of stay - ✔✔The number of days a person stays in a healthcare facility.
