Regulatory Compliance & Verification Procedures 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 Regulatory Compliance & Verification Procedures flashcards as text
Which accreditation body publishes the URAC Credentialing Standards used by managed care organizations?
Answer: URAC (formerly Utilization Review Accreditation Commission)
URAC developed and maintains its own credentialing standards for health plans and managed care organizations.
Under NCQA standards, which of the following is considered a 'red flag' that requires additional review during the credentialing process?
Answer: A history of professional liability actions exceeding the threshold defined by the organization
NCQA requires organizations to define thresholds for professional liability history that trigger additional review.
What does 'attestation' mean in the context of credentialing applications?
Answer: A practitioner's signed declaration that the information provided is true and complete
Attestation is the applicant's signed oath affirming the accuracy and completeness of the information provided on the credentialing application.
State-mandated credentialing timelines often require health plans to complete the credentialing process within:
Answer: 60 to 180 days depending on the state
Most states with credentialing regulations require health plans to complete credentialing within 60–180 days of receiving a complete application.
Which organization maintains the CAQH ProView database commonly used in credentialing?
Answer: CAQH (Council for Affordable Quality Healthcare)
CAQH operates the ProView universal credentialing database that allows providers to submit information once for use by multiple health plans.
An organization's credentialing policy requires verification of all licenses for the past 5 years. A practitioner was licensed in a state where they no longer practice. What action is required?
Answer: Verify the historical license even if it is no longer active
Credentialing policies requiring 5-year history verification necessitate confirming all licenses held during that period, active or inactive.
When a telemedicine provider seeks credentials to practice across multiple states, which regulatory framework primarily governs their licensure?
Answer: Each individual state's licensing laws where the patient is located
Telemedicine practice is governed by the laws of the state where the patient is located, requiring licensure in each patient-state.