Mixed Deck — All CPCS Topics Flashcards
100 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 20 Mixed Deck — All CPCS Topics flashcards as text
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.
How frequently must allied health professionals at Joint Commission-accredited hospitals undergo re-credentialing?
Answer: At least every two years
TJC standards require that all practitioners, including allied health professionals, be re-credentialed and re-privileged at intervals not exceeding two years.
Which document must be on file BEFORE a locum tenens practitioner sees their first patient under temporary privileges?
Answer: Completed temporary privilege application, current licensure verification, and NPDB query results
Before patient care begins, the hospital must have a completed application, verified current licensure, and NPDB query results at minimum to grant temporary privileges.
A credentialing specialist receives an application with a 6-month gap in employment history. The best course of action is to:
Answer: Request a written explanation from the applicant covering the gap period
Credentialing standards require a complete work history, and unexplained gaps must be addressed through a written explanation from the applicant.
Which of the following is NOT a typical data source for a surgeon's OPPE?
Answer: The surgeon's personal financial investment in the hospital.
OPPE data must be relevant to the practitioner's clinical performance and professional conduct. Financial information, such as personal investments, is not a valid indicator of clinical competence and should not be included in the evaluation.
The process by which Medicare requires providers to periodically resubmit and recertify the accuracy of their enrollment information is called:
Answer: Revalidation.
Medicare revalidation is a required process, typically occurring every 5 years, to ensure that the information on file with Medicare is accurate and up-to-date. This helps prevent fraud and abuse by confirming the provider's practice location, licensure, and other key details.
A peer review committee recommends termination of a physician's privileges based on quality concerns. The physician alleges the real motive is economic competition. Which federal law provides immunity to the committee if the action met its standards?
Answer: HCQIA
HCQIA provides qualified immunity to peer review participants when the process meets statutory standards of fairness and thoroughness.
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.
Which federal program requires providers to enroll before ordering or referring certain items and services for beneficiaries?
Answer: Medicare
Medicare requires ordering and referring providers to be enrolled in or validly opted out of Medicare before their orders and referrals for Medicare-covered items and services will be accepted.
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.
Which document typically defines the composition and voting rights of the medical executive committee?
Answer: The medical staff bylaws
Medical staff bylaws define the structure, composition, and voting rights of the medical executive committee.
Which entities are authorized to query the NPDB as part of the credentialing process?
Answer: Hospitals, other health care entities, and state licensing boards
Authorized queriers include hospitals, other health care entities that engage in formal peer review, and state licensing boards, among others.
Which body typically has final approval authority for granting clinical privileges to allied health professionals at an accredited hospital?
Answer: Governing board
Under accreditation standards, the governing board holds ultimate authority for approving clinical privileges for all practitioners.
What category of NPDB report is generated when a state licensing board takes an adverse action against a practitioner's license?
Answer: Adverse Action Report
State licensing boards submit Adverse Action Reports to the NPDB when they take formal disciplinary or adverse actions against a practitioner's license.
A provider's application reveals a malpractice settlement that was not disclosed on the initial application submitted two years ago. This discrepancy represents a potential issue of:
Answer: Material misrepresentation warranting investigation per policy
Undisclosed malpractice settlements are considered material misrepresentation and must be investigated through the organization's established policy process.
Which of the following is an example of a 'soft' credentialing data element that requires subjective documentation?
Answer: Peer reference assessment of clinical competence
Peer reference assessments involve subjective judgments about clinical competence rather than objective, verifiable facts.
What is 'payer mix' in the context of provider enrollment strategy?
Answer: The combination of different insurance plans a provider accepts
Payer mix refers to the distribution of different insurance plans (Medicare, Medicaid, commercial, self-pay, etc.) that a provider or practice accepts and from which they receive payment.
What is the purpose of a 'proctoring' or 'supervision' requirement attached to newly granted clinical privileges?
Answer: To allow observed evaluation of competency before independent practice is confirmed
Proctoring provides direct observation of a physician's clinical performance to validate competency before granting unrestricted independent privileges.
What is the primary purpose of a credentialing software system's 'workflow engine'?
Answer: To route credentialing applications through defined review and approval steps automatically
A workflow engine automates the routing of applications through each required review step, ensuring no stage is skipped.
What is the significance of including a 'savings clause' in medical staff bylaws?
Answer: It ensures that if one bylaw provision is found invalid, the rest remain in effect
A savings clause (severability clause) ensures that invalidating one provision does not void the entire bylaws document.