Provider Enrollment & Privileging Flashcards
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Read the first 7 Provider Enrollment & Privileging flashcards as text
A hospital receives telemedicine services from a Joint Commission-accredited distant-site hospital. Which method lets it rely on the distant site's privileging decisions?
Answer: Credentialing by proxy
CMS and Joint Commission allow originating sites to privilege telemedicine practitioners by proxy using the distant site's decisions.
What does a 'core privileges' approach to delineation mean?
Answer: A bundle of activities that any competent specialist in the field can perform
Core privileges group the routine procedures expected of any appropriately trained practitioner in a specialty.
Under NCQA standards, how often must health plans recredential practitioners?
Answer: Every 36 months
NCQA requires recredentialing at least every 36 months.
A physician requests privileges to perform robotic surgery. Which document best supports competence for this new procedure?
Answer: Case logs showing procedures performed and outcomes
Case logs with volumes and outcomes give evidence of current clinical competence for the requested privilege.
A state Medicaid program requires a provider to enroll before the provider participates in a Medicaid managed care plan network. What is the reason?
Answer: Federal rules require network providers to be screened and enrolled with the state Medicaid agency
Under the 21st Century Cures Act and 42 CFR 438.602, Medicaid managed care network providers must be enrolled with the state.
Which situation requires a provider to update Medicare enrollment within 30 days?
Answer: Change of practice location
Physicians and NPPs must report changes of practice location, ownership and adverse legal actions within 30 days.
A practitioner's privilege request covers procedures outside the hospital's available equipment and services. What should happen?
Answer: Deny or not process the request because the hospital cannot support the service
Privileges are granted only for services the organization can support with its facilities and resources.
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