CPCS CPCS - Certified Provider Credentialing Specialist Initial Application Processing Questions and Answers 2 — Questions and Answers
Question 1: 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?
- The gap must be automatically reported to the NPDB
- The practitioner's written explanation for the gap must be included in the attestation or file (Correct answer)
- The application must be denied due to unexplained history
- The gap can be ignored if the practitioner has been board certified
Correct 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.
Under NCQA credentialing standards, practitioners are required to explain any gaps in their work history of 6 months or more within the preceding 5 years. This explanation must be documented in the credentialing file, typically in the signed attestation or as a separate written explanation. Common acceptable explanations include parental leave, continuing education, health reasons, or voluntary career breaks. Unexplained gaps or gaps with concerning explanations may be flagged for credentials committee review.
Question 2: Which of the following application elements requires primary source verification rather than just a copy from the applicant?
- The practitioner's curriculum vitae (CV)
- The practitioner's current medical license (Correct answer)
- A copy of a journal article published by the practitioner
- The practitioner's personal statement
Correct 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.
Primary source verification (PSV) requires verification of credentials directly with the issuing source or a recognized equivalent (such as a national database maintained by the issuing authority). A medical license must be verified with the state medical board — not just a copy provided by the applicant — because copies can be altered or counterfeit. Acceptable PSV methods for licenses include: direct contact with the state medical board, use of a state medical board verification website, or use of a service that obtains verification from the primary source.
Question 3: When a practitioner application is received, what is the first step in processing?
- Conducting the NPDB query
- Verifying the practitioner's medical license
- Reviewing the application for completeness (Correct answer)
- Scheduling the credentials committee review
Correct 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.
Before beginning verification activities, credentialing specialists should review the received application for completeness — ensuring all required fields are completed, required documentation is included (application, attestation, CV, references, copies of credentials), and required signatures are present. Beginning verification on an incomplete application wastes resources if the application must be sent back for completion. Establishing a completeness checklist and using it consistently ensures that only complete files move forward in the process.
Question 4: 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?
- Automatically deny the application
- Request additional documentation about the suspension and refer to the credentials committee for review (Correct answer)
- Ignore the disclosure since it is outside the typical 3-year review period
- Contact the NPDB to file a report about the suspension
Correct 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.
When a practitioner discloses adverse history (such as privilege suspension, license action, or malpractice judgments), the credentialing specialist should: (1) request all relevant documentation regarding the action (hearing decisions, settlement documents, reinstatement documentation), (2) verify the NPDB report related to the action, (3) ensure the file is complete with the practitioner's explanation, and (4) refer the complete file to the credentials committee for review. The committee then makes the credentialing decision based on all available information. Automatic denial without investigation and committee review may expose the organization to HCQIA liability.
Question 5: 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?
- The physician's spouse, who is also a physician
- A physician in the same specialty who has worked alongside the applicant (Correct answer)
- A former patient who can attest to clinical competence
- The physician's personal attorney
Correct 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.
NCQA credentialing standards require at least two peer references (from practitioners in the same or related specialty who have directly observed the applicant's clinical work) as part of the initial credentialing process. References must attest to clinical competence, professional behavior, and ability to work in a collaborative environment. Family members, patients, and attorneys are not acceptable peer references. The references should be obtained directly by the credentialing organization, not provided solely by the applicant.
Question 6: A practitioner submits a credentials application listing ABMS board certification in cardiology. How should the credentialing specialist verify this credential?
- Accept the certificate copy submitted by the practitioner
- Verify directly through the ABMS website (certificationmatters.org) (Correct answer)
- Request a letter from the training program director
- Query the NPDB for board certification status
Correct 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.
The American Board of Medical Specialties (ABMS) maintains the Certification Matters website (certificationmatters.org), which provides free verification of ABMS member board certifications. This website is considered primary source verification because it is maintained by the certifying authority. A copy of the certificate provided by the practitioner is NOT primary source verification. The NPDB does not track board certification status. Training program verification confirms training completion, not certification status.
CPCS CPCS - Certified Provider Credentialing Specialist Initial Application Processing Questions and Answers 2
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?