Certified Healthcare Credentialing Specialist (CHCS) Exam — Questions and Answers

Question 1: What is URAC's primary role with respect to delegated credentialing?

Directly verifying provider credentials on behalf of all health plans
Setting federal regulations governing credentialing delegation
Providing accreditation standards for health plans and CVOs that include credentialing delegation requirements (Correct answer)
Issuing medical licenses to healthcare providers

Correct answer: Providing accreditation standards for health plans and CVOs that include credentialing delegation requirements

URAC provides accreditation standards that health plans and CVOs can be measured against, including standards addressing credentialing delegation and oversight responsibilities.

Question 2: Which of the following best describes 'focused professional practice evaluation' (FPPE)?

A time-limited review triggered by a new privilege or concern about a provider's performance (Correct answer)
An internal audit of billing practices
Annual peer review of all providers
A credentialing renewal process

Correct answer: A time-limited review triggered by a new privilege or concern about a provider's performance

FPPE is a defined period of performance monitoring used when a provider receives new privileges or when a question arises about clinical competency.

Question 3: Which of the following best describes the concept of 'collegial intervention' in medical staff governance?

A credentials committee vote
A formal peer review disciplinary process
An informal, non-punitive conversation with a practitioner about a performance concern before escalating to formal action (Correct answer)
A state medical board investigation

Correct answer: An informal, non-punitive conversation with a practitioner about a performance concern before escalating to formal action

Collegial intervention is an early, informal step where medical staff leaders speak directly with a practitioner to address a concern without triggering formal disciplinary proceedings.

Question 4: A practitioner is involved in a sentinel event during surgery. What is the most appropriate credentialing response?

Remove the event from the practitioner's file
Refer the case for focused review, which may lead to FPPE (Correct answer)
Delay review until reappointment
Grant expanded privileges

Correct answer: Refer the case for focused review, which may lead to FPPE

Sentinel events involving a practitioner warrant focused evaluation of their performance.

Question 5: Which patient safety tool proactively identifies possible process failures before they cause harm, unlike a root cause analysis?

Failure Mode and Effects Analysis (FMEA) (Correct answer)
Morbidity and mortality conference
Incident report trending
Retrospective chart audit

Correct answer: Failure Mode and Effects Analysis (FMEA)

FMEA is a proactive risk assessment that looks for failure points before an adverse event happens.

Question 6: Which situation requires a provider to update Medicare enrollment within 30 days?

New CME credits
Change of home address
New board certification
Change of practice location (Correct answer)

Correct answer: Change of practice location

Physicians and NPPs must report changes of practice location, ownership and adverse legal actions within 30 days.

Question 7: When credentialing a nurse practitioner in a state requiring physician collaboration, which document should be verified in addition to license and certification?

The collaborative practice agreement (Correct answer)
The NP's personal tax return
The NP's undergraduate transcript
A patient satisfaction survey

Correct answer: The collaborative practice agreement

Where state law requires it, the collaborative or supervisory agreement defines the NP's authorized scope.

Question 8: What is the primary role of the credentials committee in the medical staff governance structure?

Investigate malpractice claims
Set hospital financial policy
Review and recommend credentialing and privileging actions to the medical executive committee (Correct answer)
Manage HR disciplinary actions

Correct answer: Review and recommend credentialing and privileging actions to the medical executive committee

The credentials committee reviews applications, verifies qualifications, and makes recommendations to the medical executive committee before final board action.

Question 9: What is the term for verifying a provider’s education and experience directly with issuing sources?

Peer validation
Internal review
Primary source verification (Correct answer)
Reference check

Correct answer: Primary source verification

The term for verifying a provider's education and experience directly with the original issuing sources is "primary source verification." This rigorous process involves contacting institutions like universities, licensing boards, and previous employers to confirm the authenticity and validity of credentials. It is a cornerstone of credentialing, ensuring that all information is accurate and reliable, thereby safeguarding patient care.

Question 10: Which organization primarily accredits health plans and grants credentialing certification to credentials verification organizations (CVOs)?

AAAHC
CMS
NCQA (Correct answer)
The Joint Commission

Correct answer: NCQA

NCQA accredits health plans and offers CVO certification for credentialing verification services.

Question 11: Which type of organization performs credentials verification on behalf of other organizations and may be NCQA certified?

Credentials Verification Organization (CVO) (Correct answer)
Managed Services Organization (MSO) only
Independent Practice Association (IPA)
Peer Review Organization (PRO)

Correct answer: Credentials Verification Organization (CVO)

A CVO verifies practitioner credentials for other entities and can earn NCQA CVO certification.

Question 12: A hospital restricts a physician's clinical privileges for 45 days due to professional competence concerns. Within how many days must the action be reported to the NPDB?

10 days
15 days (Correct answer)
60 days
30 days

Correct answer: 15 days

Adverse privileging actions lasting more than 30 days must be reported to the NPDB within 15 days of the action.

Question 13: What primarily determines a nurse practitioner's authority to prescribe controlled substances?

Hospital medical staff bylaws alone
State scope-of-practice law, plus DEA registration (Correct answer)
The supervising physician's DEA number
National board certification only

Correct answer: State scope-of-practice law, plus DEA registration

State law defines NP prescriptive authority (full, reduced, or restricted practice), and the NP also needs DEA registration to prescribe controlled substances.

Question 14: Under the OSHA Bloodborne Pathogens Standard, within what time frame must an employer offer the hepatitis B vaccine to a newly assigned employee with occupational exposure?

Within 30 calendar days of hire
Within 10 working days of initial assignment (Correct answer)
Only after a documented exposure incident
Before the end of the 90-day probationary period

Correct answer: Within 10 working days of initial assignment

OSHA 29 CFR 1910.1030 requires the hepatitis B vaccine to be offered at no cost within 10 working days of initial assignment.

Question 15: When must a hospital query the National Practitioner Data Bank?

Only when a malpractice claim is reported
At initial appointment, at reappointment and when new privileges are requested (Correct answer)
Every 120 days
Only at initial appointment

Correct answer: At initial appointment, at reappointment and when new privileges are requested

Federal law requires NPDB queries at appointment, when privileges are added or expanded, and at least every two years.

Question 16: What should be the first action when a new regulation is enacted that affects your practice?

Delegate review to the newest team member
Assume existing procedures already comply
Wait for enforcement before making changes
Review the regulation, assess its impact, and develop an implementation plan (Correct answer)

Correct answer: Review the regulation, assess its impact, and develop an implementation plan

When new regulations are enacted, professionals should promptly review them, assess their impact on current practices, and develop a structured implementation plan.

Question 17: A physician has no plans to bill Medicare but must order lab tests for Medicare patients. Which form lets them enroll only to order and refer?

CMS-855O (Correct answer)
CMS-855I
CMS-460
CMS-855R

Correct answer: CMS-855O

The CMS-855O enrolls practitioners solely to order, certify or refer Medicare items and services.

Question 18: Which is the best example of 'economic credentialing'?

Verifying malpractice insurance coverage limits
Checking the OIG exclusion list
Denying reappointment because a physician refers patients to a competing facility (Correct answer)
Confirming DEA registration

Correct answer: Denying reappointment because a physician refers patients to a competing facility

Economic credentialing uses financial factors unrelated to quality, such as referral patterns, to make privileging decisions.

Question 19: Under the HIPAA Privacy Rule, a patient's right to request an accounting of disclosures generally covers how many years prior to the request?

Ten years
One year
Six years (Correct answer)
Thirty days

Correct answer: Six years

HIPAA allows individuals to request an accounting of certain disclosures made in the prior six years.

Question 20: Which tool helps track provider enrollment and privileges in military systems?

Credentialing management software (Correct answer)
Fitness scorecard
Leave calendar
Test evaluator app

Correct answer: Credentialing management software

Credentialing management software is the primary tool used in military systems to track provider enrollment and privileges. This specialized software centralizes all provider data, including licenses, certifications, education, and clinical privileges, allowing for efficient monitoring, updates, and re-credentialing processes. It ensures that military healthcare facilities maintain compliance and that all providers are appropriately qualified and authorized to practice.

Question 21: Privileging refers to what process in military healthcare settings?

Providing uniforms
Scheduling fitness test events
Assigning duty stations
Authorizing specific clinical duties (Correct answer)

Correct answer: Authorizing specific clinical duties

In military healthcare settings, privileging is the process of formally authorizing a healthcare provider to perform specific clinical procedures and services based on their verified credentials, experience, and demonstrated competence. This ensures that providers only perform duties for which they are qualified and proficient, thereby safeguarding patient safety and maintaining quality of care within the military health system.

Question 22: How often should ACFT data be updated in DTMS?

Only during deployments
Every six months
Once a year
Immediately after the test (Correct answer)

Correct answer: Immediately after the test

Timely data entry is vital for maintaining accurate and current records in DTMS. Updating ACFT data immediately after the test ensures that commanders have the most up-to-date information on unit readiness and individual performance. This prevents delays and potential discrepancies in reporting.

Question 23: Under Joint Commission standards, what is the maximum interval for medical staff reappointment?

12 months
48 months
24 months (Correct answer)
36 months

Correct answer: 24 months

Joint Commission requires reappointment and renewal of privileges at least every two years.

Question 24: Which form does a provider submit to receive Medicare payments by electronic funds transfer?

CMS-20134
CMS-460
CMS-588 (Correct answer)
CMS-855R

Correct answer: CMS-588

The CMS-588 is the Medicare EFT authorization agreement.

Question 25: What is the term for a formal written policy that outlines the procedures a hospital follows when making adverse credentialing decisions?

Peer review policy
Credentialing manual
Medical staff rules and regulations
Fair hearing plan (Correct answer)

Correct answer: Fair hearing plan

A fair hearing plan details the due process rights and procedures afforded to practitioners when an adverse credentialing action is being considered.

Question 26: Before engaging a new CVO for credentialing delegation, what should a hospital system evaluate?

The CVO's geographic proximity to the hospital's main campus
The CVO's marketing budget and total client count
Whether the CVO uses the same EHR system as the hospital
The CVO's accreditation status, operational processes, technology, and compliance track record (Correct answer)

Correct answer: The CVO's accreditation status, operational processes, technology, and compliance track record

Before delegating credentialing, the hospital should assess the CVO's accreditation, operational processes, technology capabilities, and compliance history to ensure they can perform functions to required standards.

Question 27: Which database feature best supports demonstrating to auditors who changed a provider's license expiration date and when?

Role-based dashboards
Scheduled report exports
An audit trail or change log (Correct answer)
Field-level validation rules

Correct answer: An audit trail or change log

An audit trail records user, date, time, and before/after values for each data change.

Question 28: Which body is the primary source for verifying graduation of an international medical graduate from a foreign medical school?

ECFMG (Correct answer)
ACGME
LCME
AOA

Correct answer: ECFMG

ECFMG certification is accepted as primary source verification of foreign medical education.

Question 29: Why is re-privileging required periodically?

To update personal data
To reduce administrative load
To maintain clinical competency (Correct answer)
To reward seniority

Correct answer: To maintain clinical competency

Re-privileging is required periodically to ensure that healthcare providers continuously maintain their clinical competency and proficiency in the specific procedures they are authorized to perform. This process involves reviewing ongoing education, performance data, and any changes in practice or scope. It is a critical mechanism for upholding patient safety and quality of care by confirming that providers remain qualified to deliver their authorized services.

Question 30: Which disease requires droplet precautions rather than airborne or contact precautions?

Measles
Varicella
Pertussis (Correct answer)
MRSA wound infection

Correct answer: Pertussis

Pertussis spreads through large respiratory droplets, so droplet precautions apply.

Question 31: Within how many days must an entity report a medical malpractice payment to the NPDB?

10 days
15 days
60 days
30 days (Correct answer)

Correct answer: 30 days

Malpractice payments must be reported to the NPDB within 30 days of the payment.

Question 32: Which document is typically required for provider enrollment?

Driver’s license
Military discharge papers
State professional license (Correct answer)
Physical fitness certificate

Correct answer: State professional license

A state professional license is a fundamental document required for provider enrollment. This license, issued by the relevant state board, legally authorizes a healthcare professional to practice their specific discipline within that state. It serves as primary evidence of their qualifications and competency, ensuring they meet the minimum standards for safe and effective patient care.

Question 33: What is the primary purpose of OPPE results?

Setting physician compensation
Calculating hospital bed capacity
Verifying medical school graduation
Deciding whether to continue, limit, or revoke existing privileges (Correct answer)

Correct answer: Deciding whether to continue, limit, or revoke existing privileges

OPPE data inform decisions to maintain, revise, or revoke privileges before or at reappointment.

Question 34: Which element is required by HCQIA for a professional review action to qualify for immunity?

Adequate notice and hearing procedures afforded to the physician (Correct answer)
A unanimous vote of the entire medical staff
Approval by the state medical board before action
Review by an outside attorney general

Correct answer: Adequate notice and hearing procedures afforded to the physician

HCQIA requires reasonable belief, reasonable fact-finding, adequate notice and hearing, and reasonable belief the action was warranted.

Question 35: A surgeon is granted a new privilege at a hospital where they already practice. Which evaluation is required?

Peer reference letter only
No evaluation is needed for current staff
OPPE
FPPE (Correct answer)

Correct answer: FPPE

Focused Professional Practice Evaluation is required for all newly granted privileges, including those for current members.

Question 36: What role does TRADOC play in ACFT compliance?

Establishes training policies (Correct answer)
Controls budget
Issues uniforms
Manages deployment orders

Correct answer: Establishes training policies

The U.S. Army Training and Doctrine Command (TRADOC) plays a crucial role in ACFT compliance by establishing the overarching training policies and doctrine for the Army. TRADOC develops the standards, methods, and guidance for physical readiness training, including the ACFT, ensuring that soldiers are properly prepared and that the test is administered according to established Army-wide protocols.

Question 37: How often should compliance procedures be reviewed and updated?

Every ten years regardless of changes
Once at initial certification and never again
Only when an audit is scheduled
Regularly, and whenever regulations change or new risks are identified (Correct answer)

Correct answer: Regularly, and whenever regulations change or new risks are identified

Compliance procedures should be reviewed regularly and updated whenever regulations change, new risks emerge, or organizational changes occur.

Question 38: A state Medicaid program requires a provider to enroll before the provider participates in a Medicaid managed care plan network. What is the reason?

MCOs cannot credential providers
Medicaid uses the Medicare PTAN
Enrollment replaces NPDB queries
Federal rules require network providers to be screened and enrolled with the state Medicaid agency (Correct answer)

Correct 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.

Question 39: How often must a practitioner's DEA controlled substance registration be renewed?

Every 3 years (Correct answer)
Every 5 years
Every 2 years
Every year

Correct answer: Every 3 years

DEA practitioner registrations are issued for a three-year period and must be renewed before expiration.

Question 40: Under the Health Care Quality Improvement Act (HCQIA), what is the primary benefit granted to peer review participants who meet the Act's standards?

Immunity from monetary damages in suits arising from the professional review action (Correct answer)
Exemption from state licensing board investigations
Automatic dismissal of any criminal charges
Complete immunity from all civil rights lawsuits

Correct answer: Immunity from monetary damages in suits arising from the professional review action

HCQIA grants qualified immunity from money damages, not from injunctive relief or civil rights claims.

Question 41: When a hospital grants 'temporary privileges' to a physician, which situation most commonly justifies this action?

The physician's reappointment application is under routine review
The physician requests expedited processing
The credentials committee is behind schedule
There is an urgent patient care need or a locum tenens situation pending full credentialing (Correct answer)

Correct answer: There is an urgent patient care need or a locum tenens situation pending full credentialing

Temporary privileges are granted for an urgent patient care need or to accommodate a locum tenens practitioner while full credentialing is completed.

Question 42: In a hospital, who has final authority to grant clinical privileges?

Department chair
Credentials committee
Medical Staff Office
Governing body (Correct answer)

Correct answer: Governing body

The medical executive committee recommends, but the governing body (board) grants privileges.

Question 43: Under NCQA standards, how often must health plans recredential practitioners?

Every 24 months
Every 12 months
Every 36 months (Correct answer)
Every 60 months

Correct answer: Every 36 months

NCQA requires recredentialing at least every 36 months.

Question 44: What should a communication plan include at minimum?

A single announcement template
Stakeholder list, message content, channels, frequency, and responsible parties (Correct answer)
Only the list of email addresses
Social media posting schedule only

Correct answer: Stakeholder list, message content, channels, frequency, and responsible parties

A comprehensive communication plan identifies stakeholders, defines message content, specifies communication channels, sets frequency, and assigns responsible parties.

Question 45: A credentialing specialist receives a query result from the NPDB showing a malpractice payment report on an applicant. What is the correct handling?

Contact the plaintiff's attorney for more information
Automatically deny the application
Review the report in context as part of the complete credentialing file and present it to the credentials committee for evaluation (Correct answer)
Ignore it if the payment was below $10,000

Correct answer: Review the report in context as part of the complete credentialing file and present it to the credentials committee for evaluation

A single NPDB malpractice payment report does not automatically disqualify a practitioner; it must be reviewed in the context of the full application file by the credentials committee.

Question 46: In the context of medical staff bylaws, 'rules and regulations' differ from bylaws because they:

Govern credentialing of nonphysician staff only
Require governing board approval to change
Are more detailed operational procedures that can typically be amended more easily than bylaws (Correct answer)
Define the mission of the hospital

Correct answer: Are more detailed operational procedures that can typically be amended more easily than bylaws

Rules and regulations provide operational detail for day-to-day medical staff functions and generally have a simpler amendment process than bylaws.

Question 47: What is 'expedited credentialing' most appropriately used for?

All new physician applications to save time
Correcting application errors
Renewing expired medical licenses
Situations where a specific patient needs care from a particular physician immediately (Correct answer)

Correct answer: Situations where a specific patient needs care from a particular physician immediately

Expedited credentialing allows a hospital to quickly verify minimum credentials for a specific patient care need when delay would harm the patient.

Question 48: When a health plan delegates credentialing to a CVO, who retains ultimate responsibility for the credentialing decisions?

The CVO
The state medical board
The delegating health plan or organization (Correct answer)
The Centers for Medicare & Medicaid Services (CMS)

Correct answer: The delegating health plan or organization

The delegating entity retains ultimate accountability and responsibility for credentialing decisions, even when functions are performed by a CVO.

Question 49: How does Emergency Procedures & Critical Care contribute to overall professional effectiveness?

It serves only as a credential requirement with no practical impact
It provides essential knowledge and skills that directly impact quality of work and outcomes (Correct answer)
It is relevant only during the certification examination
It applies only to supervisory-level professionals

Correct answer: It provides essential knowledge and skills that directly impact quality of work and outcomes

Emergency Procedures & Critical Care directly contributes to professional effectiveness by providing essential knowledge and skills that improve the quality of work and outcomes across all career levels.

Question 50: A medical staff office employee discovers a false statement on a physician's application. Under typical medical staff bylaws, this is most commonly treated as:

A minor clerical issue to be corrected silently
A reportable HIPAA breach
Grounds for denial or termination of the application (Correct answer)
An automatic grant of temporary privileges

Correct answer: Grounds for denial or termination of the application

Bylaws generally treat material misrepresentation or omission as grounds for denial or automatic relinquishment.

Question 51: A credentialing specialist notices that a physician's privilege request exceeds what their training documents support. What is the correct action?

Automatically deny the application
Forward directly to the CEO
Approve it if the physician has many years of experience
Request additional documentation of training and competency before recommending approval (Correct answer)

Correct answer: Request additional documentation of training and competency before recommending approval

Privileges must be based on documented training, experience, and demonstrated competency, so additional documentation is required before recommendation.

Question 52: Which federal database, in addition to the LEIE, should be checked for practitioners debarred from federal contracts?

ECFMG certification
CAQH ProView
SAM.gov exclusions (Correct answer)
AMA Masterfile

Correct answer: SAM.gov exclusions

The System for Award Management (SAM) lists parties excluded from federal procurement and nonprocurement programs.

Question 53: Which source is acceptable for primary source verification of graduation from a foreign medical school?

A letter from a colleague
The applicant's CV
A copy of the diploma provided by the applicant
ECFMG certification (Correct answer)

Correct answer: ECFMG certification

ECFMG certification is an accepted primary source for verifying foreign medical education.

Question 54: What is the purpose of Ongoing Professional Practice Evaluation (OPPE)?

Continuous monitoring of performance between reappointments (Correct answer)
Approval of temporary privileges
One-time verification of education
Replacement for NPDB queries

Correct answer: Continuous monitoring of performance between reappointments

OPPE continuously evaluates a practitioner's performance data to support decisions about keeping privileges.

Question 55: Which CMS regulation contains the hospital Condition of Participation for the medical staff?

45 CFR 164.502
42 CFR 485.616
42 CFR 482.22 (Correct answer)
42 CFR 482.12

Correct answer: 42 CFR 482.22

42 CFR 482.22 sets the medical staff Condition of Participation, including credentialing requirements.

Question 56: Which online system do providers use to submit and manage their Medicare enrollment electronically?

NPPES
NPDB
PECOS (Correct answer)
CAQH ProView

Correct answer: PECOS

PECOS (Provider Enrollment, Chain, and Ownership System) is CMS's online Medicare enrollment system.

Question 57: How long does a physician's Medicare opt-out last before it renews automatically unless canceled?

3 years
1 year
5 years
2 years (Correct answer)

Correct answer: 2 years

Opt-out periods run for 2 years and renew automatically unless the physician cancels at least 30 days before the period ends.

Question 58: When interpreting a practitioner's OPPE data, which benchmark is most appropriate?

The hospital CEO's personal targets
National averages for all specialties combined
Peers in the same specialty (Correct answer)
Data from a different hospital's nursing staff

Correct answer: Peers in the same specialty

Fair comparisons use practitioners with similar specialty and case mix.

Question 59: Which system is used to track ACFT scores and compliance?

TRICARE portal
Finance system
AKO Mail
DTMS (Digital Training Management System) (Correct answer)

Correct answer: DTMS (Digital Training Management System)

The Digital Training Management System (DTMS) is the official Army system used for planning, managing, and recording individual and collective training, including physical fitness tests like the ACFT. It provides a centralized platform for tracking scores, compliance, and overall unit readiness. This system is crucial for comprehensive training oversight.

Question 60: A physician's Medicare enrollment is approved, and the application was filed on June 30. What is the earliest date they can usually bill retroactively?

January 1 of that year
The approval date
May 31, 30 days before filing (Correct answer)
June 30, the filing date

Correct answer: May 31, 30 days before filing

Physicians and NPPs may bill retroactively up to 30 days before the effective filing date if they met all requirements then.

Question 61: A credentialing specialist shares a physician's peer review file with a friend at a competing hospital without authorization. This primarily violates:

The Stark Law self-referral prohibition
Confidentiality obligations protecting peer review and credentialing records (Correct answer)
The Emergency Medical Treatment and Labor Act
The Clinical Laboratory Improvement Amendments

Correct answer: Confidentiality obligations protecting peer review and credentialing records

Credentialing and peer review files are confidential and often protected by state peer review privilege statutes.

Question 62: What is the main benefit of enrolling providers in NPDB Continuous Query?

It replaces state license verification
It is free of charge
It verifies board certification
It sends automatic notification when a new report is filed on an enrolled practitioner (Correct answer)

Correct answer: It sends automatic notification when a new report is filed on an enrolled practitioner

Continuous Query alerts the organization within one business day of new reports for enrolled practitioners.

Question 63: An applicant is board certified in 'hematology.' This specialty focuses on which of the following?

Blood and blood-forming organs (Correct answer)
Skin disorders
Hormonal disorders
Muscle diseases

Correct answer: Blood and blood-forming organs

'Hemat/o' means blood, so hematology deals with blood disorders.

Question 64: A tele-ICU physician provides remote critical care services. Under CMS rules, the originating hospital may rely on which credentialing approach?

Credentialing by proxy, relying on the distant-site hospital's credentialing and privileging decisions per a written agreement (Correct answer)
The physician's self-attestation alone
Only a phone interview with the physician
No credentialing is needed for telemedicine

Correct answer: Credentialing by proxy, relying on the distant-site hospital's credentialing and privileging decisions per a written agreement

CMS Conditions of Participation allow credentialing by proxy for telemedicine under a written agreement with the distant site.

Question 65: A surgeon requests privileges for 'cholecystectomy.' What procedure is this?

Incision into the bladder
Removal of the colon
Removal of the gallbladder (Correct answer)
Repair of the bile duct

Correct answer: Removal of the gallbladder

'Chole' (bile) + 'cyst' (sac/bladder) + '-ectomy' (excision) means removal of the gallbladder.

Question 66: What is the role of documentation in regulatory compliance?

It is optional if verbal confirmation is available
It serves no practical purpose beyond record-keeping
It provides verifiable evidence that standards are being met (Correct answer)
It is only necessary for international operations

Correct answer: It provides verifiable evidence that standards are being met

Documentation provides verifiable evidence that regulatory requirements are being met and creates an audit trail for compliance verification.

Question 67: When a physician is newly granted ventilator management privileges in the ICU, what evaluation process is required by The Joint Commission?

Focused Professional Practice Evaluation (FPPE) (Correct answer)
No evaluation is required
OPPE only after two years
A state board investigation

Correct answer: Focused Professional Practice Evaluation (FPPE)

FPPE is required for all newly requested privileges to confirm competence.

Question 68: A practitioner resigns privileges while under investigation for possible incompetence. What must the hospital do?

Report it to the IRS
Report the resignation to the NPDB (Correct answer)
Notify only the patient's family
Nothing, since resignation ends the hospital's obligation

Correct answer: Report the resignation to the NPDB

Surrender of privileges while under investigation or to avoid investigation is reportable to the NPDB.

Question 69: Why is a 'primary source verification' notation important in a credentials file?

It shows the medical staff president approved the file
It documents that information was confirmed directly with the issuing source (Correct answer)
It proves the file was scanned into the electronic system
It confirms the applicant personally signed every page

Correct answer: It documents that information was confirmed directly with the issuing source

Primary source verification documents confirmation directly from the entity that issued the credential, as required by accreditors.

Question 70: What is the primary purpose of provider enrollment in military health systems?

To manage equipment allocation
To reduce patient wait times
To approve fitness training materials
To verify provider qualifications (Correct answer)

Correct answer: To verify provider qualifications

The primary purpose of provider enrollment in military health systems is to rigorously verify that healthcare providers meet all necessary qualifications, licenses, and certifications. This process ensures that only competent and qualified professionals are authorized to deliver care to service members and their families. It is a fundamental step in maintaining high standards of patient safety and quality healthcare within the military.

Question 71: Why is ongoing credential monitoring important?

To maintain valid credentials (Correct answer)
To prevent vacations
To track attendance
To update billing rates

Correct answer: To maintain valid credentials

Ongoing credential monitoring is essential to ensure that a healthcare provider's licenses, certifications, and other professional qualifications remain current and valid throughout their tenure. This continuous oversight helps identify any expirations, suspensions, or revocations promptly. It is crucial for maintaining compliance with regulatory standards and ensuring that providers are always legally and professionally qualified to practice.

Question 72: Under NCQA standards, how frequently must practitioners be recredentialed?

Every 12 months
Every 60 months
Every 24 months
At least every 36 months (Correct answer)

Correct answer: At least every 36 months

NCQA requires recredentialing at least every 36 months.

Question 73: Medicare provider enrollment records in PECOS generally must be revalidated how often for most providers?

Every year
Every 5 years (Correct answer)
Every 10 years
Every 3 years

Correct answer: Every 5 years

CMS requires most providers and suppliers to revalidate enrollment every 5 years (DMEPOS suppliers every 3).

Question 74: A practitioner's privilege request covers procedures outside the hospital's available equipment and services. What should happen?

Grant temporary privileges instead
Deny or not process the request because the hospital cannot support the service (Correct answer)
Approve it because the practitioner is qualified
Grant the privilege conditionally

Correct 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.

Question 75: In a disaster, when the emergency operations plan is activated, who may grant disaster privileges to volunteer licensed independent practitioners?

The state medical board
The charge nurse
The CEO, medical staff president or their designee (Correct answer)
Any attending physician

Correct answer: The CEO, medical staff president or their designee

Joint Commission lets individuals identified in the medical staff bylaws, such as the CEO or medical staff president, grant disaster privileges.

Question 76: A provider asks why primary source verification of their medical school diploma is needed when they already submitted a copy. What is the best explanation?

Copies are always considered forged
Accreditation standards require verification directly from the issuing source to prevent fraud (Correct answer)
It is just a hospital preference with no standard behind it
The copy was too blurry to read

Correct answer: Accreditation standards require verification directly from the issuing source to prevent fraud

Primary source verification confirms authenticity directly from the originating institution, as accreditors require.

Question 77: Which federal list must be checked to confirm a practitioner is not excluded from participating in Medicare and Medicaid?

The OIG List of Excluded Individuals/Entities (LEIE) (Correct answer)
The FSMB Physician Data Center
The AMA Physician Masterfile
The NPDB Continuous Query list

Correct answer: The OIG List of Excluded Individuals/Entities (LEIE)

The OIG LEIE identifies individuals and entities excluded from federally funded health care programs.

Question 78: What is the purpose of a pre-delegation audit when establishing a new CVO relationship?

To count the total number of providers already credentialed by the CVO
To review the CVO's financial statements and profitability
To assess whether the CVO is capable of performing delegated functions before the formal delegation begins (Correct answer)
To determine the CVO's fee structure and negotiate pricing

Correct answer: To assess whether the CVO is capable of performing delegated functions before the formal delegation begins

A pre-delegation audit assesses the prospective CVO's capabilities, processes, and compliance posture before formal delegation begins, reducing risk for the delegating entity.

Question 79: How often must a practitioner re-attest their CAQH ProView profile to keep it active?

Annually
Every 180 days
Every 30 days
Every 120 days (Correct answer)

Correct answer: Every 120 days

CAQH ProView requires re-attestation every 120 days.

Question 80: Ongoing Professional Practice Evaluation (OPPE) must be conducted at minimum how often according to The Joint Commission standards?

Monthly
Quarterly
Every 12 months (Correct answer)
Every 24 months

Correct answer: Every 12 months

TJC requires OPPE data to be collected and reviewed at least every 12 months to support reappointment decisions.

Question 81: In a clinical assessment, what does the term "chief complaint" refer to?

The primary reason the patient is seeking care (Correct answer)
The insurance company's reason for referral
The most severe diagnosis identified
The physician's primary concern

Correct answer: The primary reason the patient is seeking care

The chief complaint is the primary symptom or reason stated by the patient for seeking medical care, documented in their own words.

Question 82: A hospital restricts a physician's clinical privileges for 45 days after a professional review action. What is the NPDB reporting obligation?

A report is required because the restriction exceeds 30 days (Correct answer)
Only the state licensing board must be notified
No report is needed because the action is temporary
A report is required only if the physician appeals

Correct answer: A report is required because the restriction exceeds 30 days

Adverse privilege actions lasting more than 30 days based on competence or conduct must be reported to the NPDB.

Question 83: A practitioner requests privileges for 'arthroscopy.' What does this procedure involve?

Removal of a joint
Visual examination inside a joint (Correct answer)
Fusion of a joint
X-ray imaging of an artery

Correct answer: Visual examination inside a joint

'Arthr/o' (joint) + '-scopy' (visual examination) describes looking inside a joint with a scope.

Question 84: What does the term 'delineation of privileges' refer to in credentialing?

Outlining the provider's billing codes
Listing a provider's disciplinary history
Documenting a provider's education history
Specifying the exact clinical procedures and patient care activities a practitioner is authorized to perform (Correct answer)

Correct answer: Specifying the exact clinical procedures and patient care activities a practitioner is authorized to perform

Privilege delineation defines the specific scope of clinical activities a practitioner may perform based on their demonstrated competence and training.

Question 85: Which prefix in a medical term means 'below' or 'under'?

Sub- (Correct answer)
Supra-
Hyper-
Epi-

Correct answer: Sub-

'Sub-' means below or under, as in subcutaneous.

Question 86: A low-volume practitioner has too few cases at your hospital to produce meaningful OPPE data. What is the best approach?

Revoke all privileges automatically
Grant permanent unrestricted privileges
Obtain performance data or peer references from another facility where they actively practice (Correct answer)
Ignore OPPE for that practitioner

Correct answer: Obtain performance data or peer references from another facility where they actively practice

Organizations may supplement scant internal data with external performance information or peer evaluations.

Question 87: In addition to DEA registration, some states require practitioners to hold which separate credential to prescribe controlled substances?

An NPI number
A state controlled substance registration (CSR/CDS) (Correct answer)
A state pharmacy license
A CLIA certificate

Correct answer: A state controlled substance registration (CSR/CDS)

Many states issue their own controlled substance registrations, which credentialing staff must verify separately from the DEA.

Question 88: After a Joint Commission survey identifies requirements for improvement, the organization typically submits what document?

Corrective Action Notice
Evidence of Standards Compliance (ESC) (Correct answer)
Statement of Deficiencies
Plan of Correction to the state

Correct answer: Evidence of Standards Compliance (ESC)

TJC requires an Evidence of Standards Compliance report showing how cited issues were corrected.

Question 89: What does a 'core privileges' approach to delineation mean?

A bundle of activities that any competent specialist in the field can perform (Correct answer)
Privileges granted only to department chairs
Privileges limited to emergencies
Privileges that don't need board approval

Correct 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.

Question 90: How often must most Medicare providers and suppliers revalidate their enrollment with CMS?

Every 5 years (Correct answer)
Every 3 years
Every 2 years
Every 10 years

Correct answer: Every 5 years

Most providers revalidate Medicare enrollment every five years, while DMEPOS suppliers revalidate every three years.

Question 91: A clinic discovers a significant loss of controlled substances. Which DEA form must be filed?

DEA Form 106 (Correct answer)
DEA Form 222
DEA Form 225
DEA Form 41

Correct answer: DEA Form 106

DEA Form 106 is used to report theft or significant loss of controlled substances.

Question 92: Which HIPAA concept requires that credentialing staff access only the protected health information needed to perform their task?

Minimum necessary standard (Correct answer)
Breach notification rule
Business associate exemption
Right of access

Correct answer: Minimum necessary standard

The minimum necessary standard limits uses and disclosures of PHI to what is needed for the purpose.

Question 93: Which federal law prohibits physicians from referring Medicare patients for designated health services to entities in which they have a financial relationship, unless an exception applies?

HIPAA
Stark Law (Correct answer)
Anti-Kickback Statute
EMTALA

Correct answer: Stark Law

The Stark Law is a strict-liability self-referral prohibition for designated health services.

Question 94: Temporary privileges to meet an important patient care need for a pending applicant may last no longer than:

120 days (Correct answer)
60 days
1 year
30 days

Correct answer: 120 days

TJC limits temporary privileges for applicants pending approval to 120 days.

Question 95: When a health plan delegates credentialing to a provider group, what does NCQA require of the plan?

A written agreement and ongoing oversight, including annual evaluation of the delegate (Correct answer)
No further involvement once the contract is signed
Approval by CMS before delegation
Recredentialing every practitioner itself

Correct answer: A written agreement and ongoing oversight, including annual evaluation of the delegate

NCQA requires a delegation agreement and the organization's annual oversight of the delegate's performance.

Question 96: Accreditation of test graders helps to:

Ensure qualified evaluations (Correct answer)
Avoid using equipment
Speed up the test
Simplify instructions

Correct answer: Ensure qualified evaluations

Accreditation of test graders is essential to ensure that evaluations are conducted by qualified and competent individuals. This process verifies that graders possess the necessary knowledge, skills, and understanding of the testing standards and procedures. By ensuring qualified evaluators, accreditation helps maintain the integrity, fairness, and accuracy of test results, which is critical for reliable assessments.

Question 97: A gap in work history on an application should be documented how?

Covered by a letter from the department chair
Ignored if under 12 months in all cases
Written explanation from the applicant covering the gap period (Correct answer)
Verbal note from the credentialing specialist only

Correct answer: Written explanation from the applicant covering the gap period

Gaps exceeding the organization's threshold (often 6 months or more) require a written explanation from the applicant.

Question 98: Which institutional provider type must generally pay a Medicare enrollment application fee?

Individual physician
Nurse practitioner
Physician group of physicians only
Hospital or other institutional provider (Correct answer)

Correct answer: Hospital or other institutional provider

Institutional providers pay the application fee, while individual practitioners and physician/NPP groups are exempt.

Question 99: Which CMS enrollment form does a clinic or group practice use to enroll as a supplier organization?

CMS-855A
CMS-855S
CMS-855O
CMS-855B (Correct answer)

Correct answer: CMS-855B

Clinics, group practices and certain other suppliers enroll with the CMS-855B.

Question 100: A hospital resident without a personal DEA registration prescribes controlled substances within the scope of their training. Which is permitted under federal rules?

Prescribing without any DEA number
Using the hospital's institutional DEA number with an assigned internal suffix (Correct answer)
Using the attending physician's personal DEA number
Using a pharmacist's DEA number

Correct answer: Using the hospital's institutional DEA number with an assigned internal suffix

Under 21 CFR 1301.22, interns and residents may prescribe under the hospital's DEA registration using a specific internal code suffix.

Certified Healthcare Credentialing Specialist (CHCS) Exam

The CHCS certification validates a professional's expertise in healthcare credentialing processes, including primary source verification, privileging, and compliance with regulatory standards.

100

Questions

120 min

Time Limit

70%

To Pass

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These practice questions were written with AI tools. They are not real exam questions. We have not yet matched this exam's facts to an official source, so confirm fees, dates and rules with the exam body. Not reviewed by a subject-matter expert. Editorial policy