CPCS - Certified Provider Credentialing Specialist Initial Application Processing Questions and Answers Flashcards
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Read the first 6 CPCS - Certified Provider Credentialing Specialist Initial Application Processing Questions and Answers flashcards as text
A practitioner's application reveals a gap in work history of 8 months. Under NCQA standards, what must the credentialing file document regarding this gap?
Answer: The practitioner's written explanation for the gap must be included in the attestation or file
NCQA requires that any gap in work history of 6 months or more within the past 5 years must be explained in the practitioner's signed attestation or accompanying documentation in the file.
Which of the following application elements requires primary source verification rather than just a copy from the applicant?
Answer: The practitioner's current medical license
A medical license must be verified through primary source verification (contacting the state medical board directly or using a recognized equivalent), not just by reviewing a copy provided by the applicant.
When a practitioner application is received, what is the first step in processing?
Answer: Reviewing the application for completeness
The first step in application processing is reviewing the application for completeness to ensure all required elements are present before beginning verification activities.
A practitioner applying for network participation discloses on the application that they have had hospital privileges suspended within the past 5 years. What is the appropriate next step?
Answer: Request additional documentation about the suspension and refer to the credentials committee for review
Disclosed adverse history must be thoroughly investigated through additional documentation requests and referred to the credentials committee for review and decision — automatic denial without investigation is inappropriate.
Under NCQA standards, practitioner references must be obtained from individuals who have directly observed the applicant's clinical work. Which of the following is an acceptable reference for a physician seeking privileges?
Answer: A physician in the same specialty who has worked alongside the applicant
NCQA requires peer references from practitioners who have directly observed the applicant's clinical performance. A physician in the same specialty who has worked alongside the applicant meets this requirement.
A practitioner submits a credentials application listing ABMS board certification in cardiology. How should the credentialing specialist verify this credential?
Answer: Verify directly through the ABMS website (certificationmatters.org)
ABMS board certification must be verified directly through the ABMS Certification Matters website (certificationmatters.org) or by direct contact with the member board, which constitutes primary source verification.