CHCS CHCS Primary Source Verification & Quality Management 2 — Questions and Answers
Question 1: What is an 'acceptable equivalent' for primary source verification of a practitioner's medical degree?
- The practitioner's signed attestation
- Verification through a CVO (Credentials Verification Organization) that meets NCQA PSV standards (Correct answer)
- A letter from the practitioner's employer
- A copy of the diploma provided by the practitioner
Correct answer: Verification through a CVO (Credentials Verification Organization) that meets NCQA PSV standards
A NCQA-certified or compliant CVO can perform PSV on behalf of a health plan or hospital and their verification is accepted as equivalent to direct primary source verification.
Question 2: When a primary source is unable to verify a credential (e.g., a foreign medical school no longer exists), what is the appropriate step?
- Deny the application automatically
- Document the inability to verify and follow organizational policy, which may allow alternative verification methods (Correct answer)
- Accept the practitioner's self-attestation
- Ignore the gap and proceed
Correct answer: Document the inability to verify and follow organizational policy, which may allow alternative verification methods
When a primary source is unavailable, the credentialing specialist must document the attempt and follow policy for acceptable alternative verification methods.
Question 3: Which of the following is NOT typically a required element verified during the NCQA credentialing process?
- Board certification status
- Current DEA certificate (if applicable)
- Hospital affiliation history
- Practitioner's personal bank account information (Correct answer)
Correct answer: Practitioner's personal bank account information
Financial information is not a credentialing element; NCQA requires verification of clinical qualifications, licensure, sanctions, and work history.
Question 4: How does a Credentials Verification Organization (CVO) benefit a health plan's credentialing process?
- It replaces the governing board's decision-making authority
- It centralizes and performs PSV on behalf of multiple delegating organizations, reducing duplication (Correct answer)
- It sets national credentialing standards
- It files NPDB reports
Correct answer: It centralizes and performs PSV on behalf of multiple delegating organizations, reducing duplication
A CVO performs PSV and credential collection for multiple health plans or hospitals, eliminating redundant verification of the same practitioner by different organizations.
Question 5: In managed care credentialing, 'delegation' means that a health plan:
- Transfers credentialing authority permanently to a provider group
- Allows a delegated entity (e.g., a medical group) to perform credentialing on its behalf, subject to oversight and audit (Correct answer)
- Outsources its NPDB query responsibility to a third party
- Grants privileges to physicians without review
Correct answer: Allows a delegated entity (e.g., a medical group) to perform credentialing on its behalf, subject to oversight and audit
Delegation in credentialing means the health plan authorizes another entity to perform credentialing functions, but the health plan retains accountability and must audit the delegate.
Question 6: What is 'recredentialing' and how often is it typically required?
- Initial credentialing done for the second time; required annually
- The periodic renewal of a practitioner's credentials and privileges, typically every 2–3 years (Correct answer)
- An expedited process for urgent privilege requests; required as needed
- A disciplinary review; required after every adverse event
Correct answer: The periodic renewal of a practitioner's credentials and privileges, typically every 2–3 years
Recredentialing is the systematic re-verification of a practitioner's qualifications and performance data to support continued appointment, typically every two to three years.
CHCS CHCS Primary Source Verification & Quality Management 2
What is an 'acceptable equivalent' for primary source verification of a practitioner's medical degree?