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
Under NCQA credentialing standards, which of the following must be re-verified at recredentialing?
Answer: Current licensure, malpractice history, and NPDB query
At recredentialing, NCQA requires re-verification of current licensure, malpractice history, and a new NPDB query, among other elements.
A credentials committee discovers that a physician misrepresented his fellowship training on his application. This constitutes grounds for:
Answer: Immediate suspension or denial and potential NPDB reporting
Falsification or misrepresentation on a credentialing application is a serious violation that can result in denial or revocation of privileges and mandatory NPDB reporting.
Which standard body requires health plans to credential both MD/DO physicians and non-physician practitioners (NPPs) under the same standards?
Answer: NCQA
NCQA credentialing standards apply to both physician and non-physician practitioners, ensuring consistent verification for all licensed independent practitioners.
What is the significance of a 'clean claims' provision in a provider contract related to credentialing?
Answer: It links timely claims payment to completion of the credentialing process
Clean claims provisions establish that claims submitted by a provider will only be processed after credentialing is complete, linking payment to credentialing status.
Which element of the credentialing process is designed to assess a provider's current physical and mental ability to perform clinical duties?
Answer: Attestation of health status on the application
The attestation of health status, signed by the applicant, addresses whether the provider can perform the essential functions of the requested privileges.
A credentialing specialist receives a query from a hospital requesting verification of a provider's current staff status. Under NPDB regulations, the hospital must have which of the following to make this query?
Answer: An active credentialing file for the provider
Hospitals may query the NPDB about a practitioner only when they have an active credentialing or privileging file open for that individual.
Which credentialing model allows a provider credentialed by one entity to be recognized by another participating entity without full re-credentialing?
Answer: Reciprocal credentialing / mutual recognition
Reciprocal or mutual recognition credentialing models allow participating organizations to accept another entity's credentialing determination, reducing duplicative verification.