CPCS Accreditation Standards and Compliance 4

Question 1

A credentialing specialist discovers that a provider's malpractice insurance has lapsed mid-credentialing cycle. What is the compliance-required immediate action?

Accepted Answer

Notify the credentials committee and suspend privileges pending proof of coverage

Answer

Active malpractice coverage is a continuous credentialing requirement; lapsed coverage requires immediate notification to the committee and suspension of privileges.

Question 2

Under NCQA standards, which body is ultimately responsible for approving or denying credentials for practitioners in a health plan network?

Accepted Answer

The credentials committee or delegated credentialing entity

Answer

NCQA requires that a credentials committee or properly delegated entity—not an individual—make final credentialing decisions.

Question 3

What must a hospital do when it identifies a potential patient safety issue through the OPPE process for a credentialed provider?

Accepted Answer

Initiate an FPPE to investigate the specific concern

Answer

OPPE findings that raise safety concerns trigger an FPPE to conduct a focused, time-limited investigation before any privilege action.

Question 4

Which accreditation standard governs how an organization must handle a provider's request for a hearing following an adverse credentialing action?

Accepted Answer

Health Care Quality Improvement Act (HCQIA) fair hearing requirements

Answer

HCQIA establishes the fair hearing and appeals process that hospitals must follow when taking adverse professional review actions against practitioners.

Question 5

A delegated credentialing organization fails a NCQA delegation audit. What is the health plan's required response?

Accepted Answer

Conduct an oversight audit and develop a corrective action plan with the delegate

Answer

NCQA requires the health plan to conduct oversight, document deficiencies, and work with the delegate on a corrective action plan when audit failures occur.

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS Accreditation Standards and Compliance 4