Provider Enrollment and Payer Credentialing Processes 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 Provider Enrollment and Payer Credentialing Processes flashcards as text
A provider submits an enrollment application to Medicare and receives a 'development letter.' What does this mean?
Answer: Additional information or documentation is needed to process the application
A development letter from a Medicare contractor indicates the application is incomplete and specific additional information or supporting documents are required.
Which National Provider Identifier (NPI) type should a solo practitioner use when billing independently?
Answer: Type 1 NPI as an individual provider
Type 1 NPIs are assigned to individual health care providers, including solo practitioners billing under their own name.
A hospital-based physician group wants to enroll with a commercial payer. Which document typically outlines the contractual terms including fee schedules?
Answer: Provider Participation Agreement
The Provider Participation Agreement (also called a provider contract) outlines the terms and conditions, including reimbursement rates and fee schedules, between a provider and a payer.
Under the Medicare enrollment process, what is the purpose of the CMS-855B application?
Answer: Enrollment of clinics, group practices, and certain other suppliers
The CMS-855B is used to enroll clinics, group practices, and certain other suppliers that are not individuals into the Medicare program.
A credentialing specialist discovers a provider's DEA registration has expired. What is the most appropriate immediate action?
Answer: Notify the provider and place their privileges on hold until renewal is confirmed
An expired DEA registration is a patient safety and legal compliance issue requiring immediate notification to the provider and temporary hold on prescribing privileges until renewal is verified.
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.
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.