Primary Source Verification (PSV) Standards and Procedures Flashcards

A practitioner's medical school closed and no successor organization can be found. What is the most appropriate action for the credentialing specialist?

Answer: Research alternative verification sources such as state licensing board records or AMA profiles, document all efforts, and follow organizational policy

When a primary source is unavailable, credentialing specialists must exhaust alternative sources, document all efforts, and follow organizational policy—which may allow alternative verification pathways.

Which scenario represents a failed Primary Source Verification that requires escalation?

Answer: A training institution cannot confirm that a practitioner completed the residency they claimed on their application

When a primary source cannot confirm what a practitioner claimed—in this case residency completion—it constitutes a material discrepancy that must be escalated to the credentials committee.

What is the required action when a discrepancy is discovered between a practitioner's attestation and Primary Source Verification findings?

Answer: Document the discrepancy and refer the matter to the credentials committee per organizational policy

Discrepancies found during PSV must be documented and referred to the credentials committee, which holds the authority to determine how such findings affect appointment decisions.

Under The Joint Commission standards, which elements must be verified both at initial appointment AND at reappointment?

Answer: Current licensure, relevant training or experience, current competence, and ability to perform requested privileges

TJC requires verification of current licensure, relevant training or experience, current competence, and ability to perform privileges at both initial appointment and every reappointment.

A hospital delegates PSV to a Credentials Verification Organization (CVO). Which statement is TRUE regarding the hospital's accountability?

Answer: The hospital remains fully accountable for ensuring PSV is completed appropriately and meets accreditation standards

Even when a CVO performs PSV, the hospital retains ultimate accountability for ensuring that credentialing processes meet all accreditation and regulatory requirements.

Which element must be verified through Primary Source Verification for every practitioner seeking privileges, according to CMS Conditions of Participation?

Answer: A current, valid license to practice in the state

CMS Conditions of Participation require hospitals to verify that each practitioner holds a current, valid license as a fundamental prerequisite for granting clinical privileges.

Which best describes the role of the National Association Medical Staff Services (NAMSS) in relation to Primary Source Verification standards?

Answer: NAMSS provides best practice guidance and position statements to help credentialing professionals conduct and document PSV appropriately

NAMSS publishes best practice white papers and position statements that guide credentialing professionals, but these are advisory resources rather than legally binding regulatory standards.