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CCMC Certification - Case
Management Terms
AAPM&R - โ American Academy of Physical Medicine and Rehabilitation Access to Care - โ The ability and ease of clients to obtain healthcare when they need it. Accessible - โ A term used to denote building facilities that are barrier-free thus enabling all members of society safe access, including persons with physical disabilities. Accountable Care Organization (ACO) - โ 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. ACO's became popular in the Medicare fee-for-service benefit system as a result of the Affordable Care Act. Accreditation - โ A standardized program for evaluating healthcare organizations to ensure a specified level of quality, as defined by a set of national industry standards. Organizations that meet accreditation standards receive an official authorization or approval of their services. Accreditation entails a voluntary survey process that assesses the extent of a healthcare organization's compliance with the standards for the purpose of improving the systems and processes of care (performance) and, in so doing, improving client outcomes. Actionable Tort - โ A legal duty, imposed by statute or otherwise, owing by defendant to the one injured.
Active Listening - โ A structured way of communication and interacting in which one is actively engaged with the speaker primarily through focused attention and suspension of one's own frame of reference, biases, distractions and judgment. A communication technique that improves personal relationships, fosters understanding, and facilitates cooperation and collaboration and eliminates conflict. Activities of Daily Living (ADLs) - โ Routine activities an individual tends to do every day for self-care and normal living. These include eating, bathing, grooming, dressing, toileting, transferring (such as walking, bed to chair) and continence. Assessment of an individual's ability to perform these ADLs is important for determining an individual's ability, independence, disability or limitations. This assessment determines the type of long-term care and benefit coverage the individual needs. care may include placement in a nursing home, skilled care facility or home care services.Benefit coverage may include Medicare, Medicaid or long-term care insurance. Activity Limitations - โ Difficulties an individual may have in executing activities. An activity limitation may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition. Actual Value - โ Also referred to as real 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 - โ Statistical analysis of a population based on its utilization of healthcare services and demographic trends of the population. Results used to estimate healthcare plan premiums or costs.
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 - โ Developed by the School of Public Health at Johns Hopkins University, this system clusters clients into homogeneous groups (102 discrete groups) based on a unique approach 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. The System accounts for the burden of morbidity in a client population based on disease patterns, age, and gender and relies on the diagnostic and/or pharmaceutical code information found in insurance claims or other computerized client health records Adjuster - โ A person who handles claims (also referred to as Claims Service Representative). Administrative Law - โ That branch of public law that deals with the various organizations of federal, state, and local governments which prescribes in detail the manner of their activities. Administrative Services Only (ASO) - โ An insurance company or third party administrator (TPA) that delivers administrative services to an employer group. This usually requires the employer to be at risk for the cost of healthcare services provided, which the ASO processes and manages claims. Admission Certification - โ 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. Admission certification ensures that 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 the services are approved.
Admission Review - โ A review that occurs within 24 hours of a client's admission to a healthcare facility (e.g., a hospital) or according to the time frame required in the contractual agreement between the healthcare provider and the health insurance plan. This review ensures that the client's care in an inpatient setting is necessary, based on the client's health condition and intensity of the services needed. Advance Directive - โ Legally executed document that explains the client's healthcare related wishes and decisions. It is drawn up while the client is still competent and is used if the client becomes incapacitated or incompetent. Adverse Events - โ Any untoward occurrences, which under most conditions are not natural consequences of the client's disease process or treatment outcomes. Advocacy - โ The act of recommending, pleading the cause of another; to speak or write in favor of. (CMSA Standards of Practice, 2010, p 24). Advocate - โ A person or agency who speaks on behalf of others and promotes their cause. Affect - โ The observable emotional condition of an individual at any given time. Affidavit - โ A written statement of fact signed and sworn before a person authorized to administer an oath. Aggregated Diagnosis Groups (ADGs) - โ A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a client's health condition over time. An individual client can suffer more than one health condition and therefore may have more than one ADG (total of 32 ADG clusters). Individual diseases or conditions are placed into a single ADG based on a set of criteria including
ANCC - โ American Nurses Credentialing Center Ancillary Services - โ Other diagnostic and therapeutic services that may be involved in the care of clients other than nursing or medicine. Includes respiratory, laboratory, radiology, nutrition, physical and occupational therapy, and pastoral services. APC - โ Ambulatory Payment Classification Appeal (Care Provision Related) - โ The formal process or request to reconsider a decision made not to approve an admission or healthcare services, reimbursement for services rendered, or a client's request for postponing the discharge date and extending the length of stay. Appeal (Legal in Nature) - โ The process whereby a court of appeals reviews the record of written materials from a trial court proceeding to determine if errors were made that might lead to a reversal of the trial court's decision Appropriateness of Setting - โ Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible. Approval - โ To offer or receive affirmation, sanction, or agreement about a decision, action, service, treatment, or intervention. In the area of health insurance, it is the act of authorizing or affirming a service to a client that implies agreement to be responsible for reimbursing the provider of the service the related cost of providing the service to a client/support system Approved Charge - โ The amount Medicare pays a physician based on the Medicare fee schedule. Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.
ASO - โ Administrative Services Only Assessing - โ The process of collecting in-depth information about a client and her/his support system in order to identify the needs and decide upon the best case management services to address these needs. Similar to screening, however to a greater depth. Assessment - โ The process of collecting in-depth information about a person's situation and functioning to identify individual needs in order to develop a comprehensive case management plan that will address those needs. In addition to direct client contact, information should be gathered from other relevant sources Assignment of Benefits - โ Paying medical benefits directly to a provider of care rather than to a member. This system generally requires either a contractual agreement between the health plan and provider or written permission from the subscriber for the provider to bill the health plan. Assistive Device - โ Any tool that is designed, made, or adapted to assist a person to perform a particular task. Assistive Technology - โ Any item, piece of equipment, or product system, whether acquired commercially or off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. Assistive Technology Services - โ Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device. Assumption of Risk - โ A doctrine based upon voluntary exposure to a known risk. It is distinguished from contributory negligence, which is based on carelessness, in that it involves a comprehension that a peril is to be encountered and a willingness to encounter it.
Beneficence - โ Compassion; taking positive action to help others; desire to do good; core principle of client advocacy. Beneficiary - โ An individual eligible for benefits under a particular plan. In managed care organizations beneficiaries may also be known as members in HMO plans or enrollees in PPO plans. Benefit Package - โ The sum of services for which a health plan, government agency, or employer contracts to provide. In addition to basic physician and hospital services, some plans also cover prescriptions, dental, and vision care. Benefit Programs - โ Government agency, or employer to individuals based on some sort of an agreement between the parties; for example between an employer and an employee. Benefits vary based on the plan and may include physician and hospital services, prescriptions, dental and vision care, workers' compensation, long-term care, mental and behavioral health, disability and accidental death, counseling and other therapies such as chiropractor care. Benefits - โ Principal Term: The type of health and human services covered by an insurance company/health plan and as agreed upon between the plan/insurance company and the individual enrollee or participant. Benefits also refers to the amount payable by an insurance company to a claimant or beneficiary under the claimant's specific coverage as stipulated in the agreed upon health plan. Beyond (Outside) - the - Walls Case Management - โ Models where healthcare resources, services and case managers are based externally to an acute care/hospital setting, that is in the community. Board Certified Case Manager - โ A case manager who has earned the certified case manager (CCM) credential offered by the Commission for Case Manager Certification (CCMC). This involves
passing an evidence-based certification examination after meeting a set of criteria that qualifies the case manager to sit for the examination. Once certified, the case manager must maintain the certification by acquiring ongoing education through means of continuing education units (CEUs), and uphold the CCM Code of Professional Conduct for Case Managers. Body of Knowledge (BOK) - โ Widely recognized information, standards, methods, tools, and practices about a specific field. A BOK usually includes a comprehensive set of concepts, terms, tools, and activities that make up a profession, as defined by a relevant professional society. While the term body of knowledge is used to describe the document that defines that knowledge, the body of knowledge itself is a dynamic reference that "is more than simply a collection of terms and concepts; a professional reading list; a library; a website or a collection of websites; a description of professional functions; or even a collection of information" (Wikipedia, 2010). Therefore, one may then describe a BOK as a prescribed aggregation of essential knowledge in a particular field or specialty an individual within the field is expected to have mastered to effectively practice and be considered a practitioner within the specialty (Babylon Online Dictionary, 2009). BOK - โ Body of Knowledge Bona Fide - โ "In Good Faith" Brain Disorder - โ A loosely used term for a neurological disorder or syndrome indicating impairment or injury to brain tissue. Brain Injury - โ Any damage to tissues of the brain that leads to impairment of the function of the Central Nervous System.
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. Care Guidelines - โ Nationally recognized and professionally supported plans of care recommended for the care management of clients with a specific diagnosis or health condition and in a particular care setting. Usually developed based on the latest available evidence and modified as necessary by healthcare professionals upon implementation for the care of an individual client. See also case management plan. Care Management - โ A healthcare delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly. It also helps avoid unnecessary services by preventing medical problems from escalating. Care Setting - โ A place across the continuum of health and human services where a client may receive healthcare services dependent on need. Care settings vary based on intensity and complexity of the services provided to clients; that is, from least complex (e.g., prevention and wellness) to most complex (e.g., acute and critical care services). Caregiver - โ The person responsible for caring for a client in the home setting. Can be a family member, friend, volunteer, or an assigned healthcare professional. CARF - โ Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards. Carpal Tunnel Syndrome - โ The name given to the symptoms that occur when the nerves and tendons running through the carpal tunnel of the wrist are compressed by tissue or bone or
become irritated and swell.The carpal tunnel itself is a narrow passage in the wrist comprised of bones and ligaments through which nerves and tendons pass into the hand. Also referred to as "Cumulative Trauma Injury/Disorder," "Repetitive Motion Injury," and "Repetitive Stress Syndrome." Carrier - โ The insurance company or the one who agrees to pay the losses. A carrier may be organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters. Carve Out - โ Services excluded from a provider contract that may be covered through arrangements with other providers. Providers are not financially responsible for services carved out of their contract. Case-Based Review - โ The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professionals assigned by the hospital or an outside agency (e.g., Peer Review Organization [PRO]). Case Closure - โ Terminating the provision of case management services to aclient/support system. The process of communicating the decision to terminate services to clients/support systems, payor representative, and other healthcare professional involved. Case Conference - โ A multidisciplinary healthcare team meeting that is held to discuss a client or client's support system situation such as conflict in decision making between the client and client's support system, clarification of plan of care and prognosis, end of life issues, or an ethical dilemma. Depending on the purpose of the conference, the client and client's support system may or may not participate in the meeting. Other participants are the case manager, social worker, physician of record or primary care provider, specialty care provider, registered nurse, registered dietitian, physical therapist,
usually developed prospectively by an interdisciplinary healthcare team in relation to a patient's diagnosis, health problem, or surgical procedure.
