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
When a health plan delegates credentialing to a medical group, the health plan retains responsibility for which of the following?
Answer: Oversight and final approval of the delegation arrangement
Even when credentialing is delegated, the health plan retains ultimate accountability and must maintain oversight of the delegated entity's compliance.
A physician applies for privileges in a specialty she has not practiced in two years. Which criterion is MOST relevant to the credentials committee?
Answer: Recency and volume of relevant clinical activity
Current clinical competence is demonstrated through recent and sufficient volume of practice in the relevant specialty area.
Which element is NOT typically verified through primary source verification during initial credentialing?
Answer: Provider's personal references
Personal references are collected but are not obtained directly from a primary (original) source — they are peer references solicited from individuals named by the provider.
URAC's credentialing standards most directly apply to which type of organization?
Answer: Health plans and managed care organizations
URAC accredits health plans and managed care organizations and sets credentialing standards specifically applicable to those entities.
What is the maximum timeframe NCQA allows for completing the initial credentialing process once an application is deemed complete?
Answer: 180 days
NCQA standards require organizations to complete the credentialing process within 180 days of receiving a complete application.
Which query is mandatory when credentialing a DEA-registered practitioner?
Answer: National Practitioner Data Bank (NPDB)
The NPDB must be queried for all practitioners applying for clinical privileges, regardless of DEA registration status.
A credentialing file is missing a reference letter. Under due-diligence standards, what should the specialist do?
Answer: Contact the provider to obtain the missing reference
The specialist must attempt to obtain all required documentation, including following up with the provider to secure the missing reference.