- Certified Case Manager Reimbursement and Utilization Management Questions and Answers Flashcards
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What is the Medicaid program?
Answer: A joint federal-state program providing health coverage to low-income individuals, families, and people with disabilities
Medicaid is a joint federal-state program providing coverage to eligible low-income and disabled individuals.
What is a capitated payment model?
Answer: A fixed per-member-per-month payment covering all contracted services regardless of utilization
Capitation pays a fixed PMPM amount to cover all contracted services, incentivizing efficient coordination.
What is the SNF 3-day qualifying stay requirement?
Answer: Must have an inpatient hospital stay of at least 3 consecutive days before Medicare covers SNF care
Medicare Part A requires at least 3 consecutive inpatient hospital days before covering SNF care.
What is the purpose of the appeals process in utilization management?
Answer: A formal mechanism for challenging adverse coverage determinations
The appeals process provides a mechanism for challenging denied or reduced coverage decisions.
What is a bundled payment model?
Answer: A single payment covering all services during a defined episode of care
Bundled payments provide a single payment for all services during a defined care episode.
What is a Medicaid waiver?
Answer: An authorization allowing states to waive certain requirements to test innovative approaches, often expanding HCBS
Waivers allow states to deviate from standard rules to test innovative approaches, particularly HCBS.