CHCS Delegated Credentialing & CVO Operations 1 — Questions and Answers
Question 1: What is a Credentials Verification Organization (CVO)?
- A government agency that issues medical licenses
- An organization that performs credentialing verification functions on behalf of a health plan or hospital (Correct answer)
- A professional association for credentialing specialists
- A software platform for storing provider credentials
Correct answer: An organization that performs credentialing verification functions on behalf of a health plan or hospital
A CVO is an organization contracted to perform credentialing verification activities on behalf of another entity, such as a health plan or hospital system.
Question 2: 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 3: What document formally establishes the terms of a credentialing delegation arrangement?
- Medical staff bylaws
- Credentialing policy manual
- Delegation agreement (Correct answer)
- Provider participation agreement
Correct answer: Delegation agreement
A delegation agreement is the formal contract that outlines responsibilities, oversight requirements, and performance standards between the delegating entity and the CVO.
Question 4: According to NCQA standards, how often must a delegating organization conduct an audit of its CVO's credentialing activities?
- Monthly
- Quarterly
- At least annually (Correct answer)
- Every three years
Correct answer: At least annually
NCQA requires delegating organizations to audit their CVOs' credentialing activities at least annually to ensure compliance with standards.
Question 5: What is the primary purpose of an oversight audit in a delegated credentialing arrangement?
- To verify that the CVO is profitable
- To ensure the CVO is performing delegated functions in compliance with the delegation agreement and applicable standards (Correct answer)
- To count the number of providers credentialed each year
- To review provider patient satisfaction scores
Correct answer: To ensure the CVO is performing delegated functions in compliance with the delegation agreement and applicable standards
Oversight audits verify that the CVO is fulfilling its delegated responsibilities according to the agreement terms and accreditation standards.
Question 6: Which accrediting body's standards most directly address credentialing delegation requirements for managed care health plans?
- The Joint Commission
- URAC
- NCQA (Correct answer)
- The American Medical Association
Correct answer: NCQA
NCQA's accreditation standards most directly address credentialing delegation requirements for health plans, including what must be in delegation agreements and oversight expectations.
Question 7: What action must a delegating organization take if a CVO fails an oversight audit?
- Immediately terminate the delegation agreement
- Report the failure to the state insurance commissioner
- Work with the CVO on a corrective action plan or revoke the delegation if deficiencies persist (Correct answer)
- Notify all providers credentialed by the CVO
Correct answer: Work with the CVO on a corrective action plan or revoke the delegation if deficiencies persist
When a CVO fails an audit, the delegating organization must implement a corrective action plan with the CVO or revoke delegation if deficiencies cannot be corrected in a timely manner.
CHCS Delegated Credentialing & CVO Operations 1
What is a Credentials Verification Organization (CVO)?