CHCS Delegated Credentialing & CVO Operations 2 — Questions and Answers
Question 1: Which elements must typically be included in a delegation agreement between a health plan and a CVO?
- Provider salary information and billing codes
- Scope of delegated activities, performance standards, and audit requirements (Correct answer)
- Patient health records and clinical outcomes data
- Marketing strategies and enrollment targets
Correct answer: Scope of delegated activities, performance standards, and audit requirements
Delegation agreements must specify the scope of delegated functions, performance expectations, and how the delegating entity will monitor and audit the CVO's performance.
Question 2: What does 'sub-delegation' mean in the context of credentialing?
- A CVO hiring additional credentialing staff internally
- When a CVO further delegates credentialing functions to another organization (Correct answer)
- A health plan performing credentialing for a subsidiary company
- When a provider delegates credentialing authority to a practice manager
Correct answer: When a CVO further delegates credentialing functions to another organization
Sub-delegation occurs when a CVO that has received delegated credentialing authority further delegates those functions to another organization, which typically requires approval from the original delegating entity.
Question 3: A health plan reviews a CVO's file audit and finds that 15% of files are missing primary source verifications. What is the most appropriate next step?
- Immediately revoke all credentialing decisions made by the CVO
- Issue a corrective action plan requiring the CVO to remediate deficiencies within a specified timeframe (Correct answer)
- Notify the state medical board about the deficiencies
- Extend the delegation agreement for an additional year to allow more time
Correct answer: Issue a corrective action plan requiring the CVO to remediate deficiencies within a specified timeframe
A corrective action plan with specific remediation timelines is the appropriate response to audit deficiencies, giving the CVO the opportunity to correct issues before more drastic action is taken.
Question 4: Which NCQA standard element specifically addresses the requirements for credentialing delegation in health plans?
- QI (Quality Improvement)
- UM (Utilization Management)
- CR (Credentialing and Recredentialing) (Correct answer)
- MBR (Member Rights and Responsibilities)
Correct answer: CR (Credentialing and Recredentialing)
NCQA's CR (Credentialing and Recredentialing) standards include specific requirements for delegation arrangements, including delegation agreement content and oversight audit requirements.
Question 5: What is URAC's primary role with respect to delegated credentialing?
- Issuing medical licenses to healthcare providers
- Providing accreditation standards for health plans and CVOs that include credentialing delegation requirements (Correct answer)
- Directly verifying provider credentials on behalf of all health plans
- Setting federal regulations governing credentialing delegation
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 6: In a delegated credentialing arrangement, which party is responsible for notifying providers of credentialing decisions?
- Always the CVO, as the entity performing verification
- Always the delegating health plan, as the accountable party
- The party specified in the delegation agreement, though the delegating entity remains ultimately accountable (Correct answer)
- The state licensing board where the provider is licensed
Correct answer: The party specified in the delegation agreement, though the delegating entity remains ultimately accountable
The delegation agreement specifies which party handles provider notifications, but the delegating organization retains ultimate accountability for ensuring appropriate communication occurs.
Question 7: What is the significance of NCQA's CVO certification or 'deemed status' in credentialing delegation?
- It exempts a CVO from all oversight audits by delegating entities
- A CVO with NCQA certification may be recognized as meeting certain delegation standards, potentially reducing duplicative auditing requirements (Correct answer)
- It allows a CVO to credential providers without primary source verification
- It grants the CVO authority to make final adverse credentialing decisions independently
Correct answer: A CVO with NCQA certification may be recognized as meeting certain delegation standards, potentially reducing duplicative auditing requirements
NCQA-certified CVOs may receive recognition where the delegating health plan can treat the CVO's accreditation as evidence of meeting certain standards, potentially streamlining oversight audit requirements.
CHCS Delegated Credentialing & CVO Operations 2
Which elements must typically be included in a delegation agreement between a health plan and a CVO?