CPCS - Certified Provider Credentialing Specialist Initial Application Processing Questions and Answers

Question 1

A credentialing specialist receives an initial application from a physician. Which of the following elements is required to be verified from a primary source according to both TJC and NCQA standards?

Accepted Answer

Medical school education

Answer

Peer references

Answer

The applicant's explanation of a malpractice claim

Answer

The applicant's attestation statement

Question 2

When reviewing a new provider's application, the credentialing specialist notes a 7-month gap between the completion of residency and the first listed employment. According to TJC guidelines, what is the MOST appropriate next step?

Accepted Answer

Request a written explanation from the provider for any time gaps typically greater than 30 days.

Answer

Reject the application due to the unexplained gap.

Answer

Assume the provider was on vacation and proceed with processing.

Answer

Contact the residency program to inquire about the provider's departure date.

Question 3

A provider submits an initial application that is missing a copy of their current DEA certificate. The credentialing specialist has already sent one email request for the missing document. Which of the following actions aligns with best practices for processing the application?

Accepted Answer

Continue to process the application and obtain the DEA verification from the primary source.

Answer

Hold the application until the provider submits the missing document, as it is required for a complete application.

Answer

Deny the application for being incomplete after the initial request.

Answer

Ask the provider's office manager to verbally confirm the DEA number over the phone.

Question 4

Which of the following is a primary objective of the initial application processing phase in provider credentialing?

Accepted Answer

To gather and verify practitioner qualifications to ensure they meet organizational and regulatory standards.

Answer

To negotiate the provider's reimbursement rates with health plans.

Answer

To schedule the provider for their first week of patient appointments.

Answer

To complete ongoing professional practice evaluation (OPPE).

Question 5

During the analysis of an initial application, a credentialing specialist must ensure compliance with various standards. According to NCQA, an organization must have policies that address which of the following?

Accepted Answer

Non-discrimination in the credentialing and recredentialing process.

Answer

The number of continuing medical education (CME) credits required annually.

Answer

The provider's on-call schedule availability.

Answer

The brand of malpractice insurance the provider must carry.

Question 6

A new physician is applying for privileges at a hospital. The application asks for documentation of competency for specific procedures. Which of the following would be the LEAST acceptable form of documentation for demonstrating current competency?

Accepted Answer

A letter from the residency program director attesting to the procedures performed during training that ended 5 years ago.

Answer

Case logs from the last 24 months from another hospital where the physician holds privileges.

Answer

A letter of recommendation from a current partner in their private practice.

Answer

Documentation of recent, relevant Continuing Medical Education (CME) courses.