Credentialing Processes & Accreditation Standards Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Credentialing Processes & Accreditation Standards flashcards as text
Which accreditation body sets standards for hospital credentialing programs in the United States?
Answer: The Joint Commission (TJC)
The Joint Commission establishes and enforces credentialing standards for hospitals and other healthcare organizations seeking accreditation.
What is the primary purpose of a Credentials Verification Organization (CVO)?
Answer: To independently verify practitioner credentials on behalf of health plans or facilities
A CVO performs primary source verification and other credentialing functions as a delegated agent for health plans or healthcare organizations.
Under NCQA standards, how often must a delegated credentialing entity submit an audit file to the delegating organization?
Answer: Annually
NCQA requires delegating organizations to audit delegated entities at least annually to ensure compliance with credentialing standards.
A provider's application reveals a malpractice settlement five years ago. What is the credentialing specialist's MOST appropriate next step?
Answer: Request the provider's explanation and obtain details of the settlement
The specialist should gather complete information about the settlement, including the provider's explanation, before the credentials committee makes a determination.
Which document establishes the criteria a medical staff must meet for granting clinical privileges?
Answer: Bylaws and credentialing policies
Medical staff bylaws and credentialing policies define the criteria, process, and standards for granting, modifying, or denying clinical privileges.
What is 'focused professional practice evaluation' (FPPE)?
Answer: A time-limited evaluation of a newly privileged or newly appointed practitioner
FPPE is a time-limited, focused evaluation process used to assess competence of practitioners who are new to an organization or who receive new privileges.
Which federal law requires hospitals to report adverse credentialing actions to the National Practitioner Data Bank (NPDB)?
Answer: The Health Care Quality Improvement Act (HCQIA)
The Health Care Quality Improvement Act of 1986 established the NPDB and mandates reporting of adverse actions against practitioners' clinical privileges.