MCQ 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 MCQ flashcards as text
Under NCQA credentialing standards, which of the following may be used as an acceptable alternative to primary source verification of board certification?
Answer: Verification via the certifying board's online database
NCQA accepts verification through a certifying board's publicly available online database as equivalent to primary source verification.
Which of the following is a key responsibility of a credentials committee?
Answer: Making recommendations on granting, denying, or modifying clinical privileges
The credentials committee reviews credentialing files and recommends privilege decisions to the governing body.
What does the term 'clean claim' mean in the context of provider credentialing and enrollment?
Answer: A claim that can be processed without additional information or investigation
A clean claim contains all required information and can be adjudicated by the payer without additional documentation.
A managed care organization delegates credentialing to a hospital. Which element is essential for a compliant delegation agreement?
Answer: The MCO retains the right to approve, deny, or rescind privileges
In delegated credentialing, the MCO must retain oversight authority including the right to approve, deny, or rescind provider participation.
Which database should be queried to identify providers sanctioned under Medicare or Medicaid programs?
Answer: OIG List of Excluded Individuals and Entities (LEIE)
The OIG LEIE specifically identifies individuals and entities excluded from participation in federal healthcare programs including Medicare and Medicaid.
A credentialing specialist discovers that a provider's work history contains a gap of 18 months with no explanation. What is the most appropriate action?
Answer: Request a written explanation from the provider for the gap period
Requesting a written explanation for the unexplained gap allows the provider to clarify and ensures the file is complete before a decision is made.
Which privileging model grants providers permission to perform specific procedures based on demonstrated training and competency?
Answer: Delineation of privileges
Delineation of privileges is the process of specifying exactly which clinical activities a practitioner is authorized to perform based on credentials and competency evidence.