Knowledge 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 Knowledge flashcards as text
Which federal law established the Healthcare Integrity and Protection Data Bank (HIPDB), later merged with the NPDB?
Answer: Health Insurance Portability and Accountability Act (HIPAA) of 1996
HIPAA created the HIPDB to combat fraud and abuse; it was merged into the NPDB in 2013.
A Credentials Verification Organization (CVO) that seeks NCQA certification must demonstrate what key capability?
Answer: Performing primary source verification according to NCQA's credentialing standards
NCQA CVO certification requires the CVO to conduct primary source verification processes consistent with NCQA credentialing standards.
Under The Joint Commission standards, which committee typically has final authority over clinical privileging decisions?
Answer: The Governing Board
While the Medical Executive Committee recommends privileges, TJC standards place ultimate authority for granting, limiting, or revoking privileges with the Governing Board.
A practitioner who holds a time-limited license with conditions imposed by the state board should trigger which credentialing action?
Answer: Further investigation and reporting to the appropriate committee for review
A conditional or restricted license is a red flag that must be investigated and referred to the credentials or medical executive committee for a determination.
What is the significance of the 'clean claims' period in the context of a practitioner's malpractice insurance verification?
Answer: It is the period without any reported malpractice claims used to assess risk history
A 'clean claims' period reflects years without malpractice claims, which credentialers use to evaluate a practitioner's liability risk profile.
Which element is NOT typically required in an initial credentialing application for a physician?
Answer: Proof of board certification in a specialty
Board certification is desirable but not universally required for credentialing; eligibility or lack of board certification must be addressed per the organization's criteria.
Which statute requires hospitals that receive Medicare/Medicaid funds to query the NPDB when credentialing practitioners?
Answer: Medicare and Medicaid Patient and Program Protection Act of 1987
The Medicare and Medicaid Patient and Program Protection Act of 1987 mandates that hospitals query the NPDB as part of the credentialing process.