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 credentialing specialist is reviewing a provider's work history and finds an unexplained gap of 8 months. What is the standard best practice?
Answer: Request a written explanation from the provider detailing the gap period
Standard credentialing practice requires providers to account for all gaps in employment or training history of typically 30 days or more, usually through a written explanation.
What is the primary function of the CAQH ProView database in the credentialing process?
Answer: It serves as a centralized repository for provider credentialing data used by multiple payers
CAQH ProView is a centralized platform where providers store their credentialing information, which participating payers can then access to streamline the credentialing process.
A provider is enrolled with Medicare as a 'non-participating' provider. What does this status mean for Medicare beneficiaries?
Answer: The provider may see Medicare patients but must accept limiting charges, not full assignment
Non-participating providers can still treat Medicare patients but do not accept assignment on all claims; they may charge up to the limiting charge (115% of the non-par fee schedule amount).
During initial credentialing, which source is considered the most authoritative for verifying a physician's board certification?
Answer: The certifying specialty board directly (Primary Source Verification)
Primary Source Verification (PSV) requires obtaining information directly from the issuing organization, such as the certifying specialty board, which is the gold standard for verifying credentials.
What does 'clean claim' mean in the context of provider enrollment and billing?
Answer: A claim submitted with all required data elements and no deficiencies that would prevent processing
A clean claim contains all required data elements, is free from deficiencies, and can be adjudicated by the payer without the need for additional information.
Which entity maintains the National Practitioner Data Bank (NPDB) and makes it available for credentialing queries?
Answer: Health Resources and Services Administration (HRSA)
The NPDB is maintained by the Health Resources and Services Administration (HRSA), a division of the U.S. Department of Health and Human Services.
A provider group receives a 'withhold' notification from a managed care organization. In credentialing context, what does this typically indicate?
Answer: A percentage of reimbursement is being held back pending performance or quality metrics
A withhold in managed care refers to a portion of the provider's payment that the MCO holds back and returns (in whole or part) based on meeting quality, utilization, or financial targets.