CPCS - Certified Provider Credentialing Specialist Credentialing Information Management Questions and Answers Flashcards
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When a credentialing specialist discovers a discrepancy between information on a practitioner's application and a primary source response, what is the appropriate action?
Answer: Contact the practitioner for an explanation and document the discrepancy and resolution in the file
When a discrepancy is found, the specialist should contact the practitioner for explanation, document the discrepancy, the practitioner's response, and the resolution in the credentialing file.
Which of the following elements is typically included in a 'query' to the National Practitioner Data Bank (NPDB)?
Answer: A request for information about adverse actions, malpractice payments, and exclusions
NPDB queries return information about: medical malpractice payments, adverse licensure and clinical privilege actions, federal/state exclusions, DEA certificate actions, and negative actions by professional societies.
Under NCQA credentialing standards, how frequently must health plans query the NPDB for current network practitioners?
Answer: Every three years
NCQA requires health plans to query the NPDB at initial credentialing and at recredentialing, which occurs every three years. Some organizations query more frequently, but NCQA's minimum requirement aligns with the recredentialing cycle.
A credentialing specialist is auditing files and finds that 15% of practitioner files are missing current malpractice insurance certificates. What type of report should be generated?
Answer: Credentialing exception or deficiency report
Missing required credentialing elements like malpractice insurance certificates are documented in a credentialing exception or deficiency report, which tracks files that are out of compliance with required elements.
Which of the following best describes 'continuous monitoring' in the context of credentialing information management?
Answer: Running ongoing automated checks against sanction lists, license verification databases, and exclusion lists between credentialing cycles
Continuous monitoring involves automated, ongoing checks against exclusion lists (OIG LEIE, SAM.gov), state license databases, and other sources between the three-year credentialing cycles to identify issues as they arise.
Why is it important to document the date and method of primary source verification in a credentialing file?
Answer: It demonstrates compliance with accreditation standards and provides an audit trail if the verification is challenged
Documenting the date, source, and method of verification creates an audit trail that demonstrates compliance with accreditation standards and provides evidence that proper due diligence was performed if verification accuracy is later questioned.