CPCS Accreditation Standards and Compliance 5 — Questions and Answers
Question 1: Under CMS Conditions of Participation, which practitioner category is explicitly required to be credentialed and privileged by the hospital medical staff?
- Only physicians with admitting privileges
- All licensed independent practitioners (LIPs) who provide patient care (Correct answer)
- Only practitioners with surgical privileges
- All hospital employees regardless of clinical role
Correct answer: All licensed independent practitioners (LIPs) who provide patient care
CMS requires that all licensed independent practitioners who are permitted to provide patient care services within the hospital undergo credentialing and privileging.
Question 2: A provider requests privileges for a newly FDA-approved procedure that the hospital has never offered. What is the accreditation-compliant first step?
- Grant privileges based on the provider's training certificate alone
- Develop criteria for the new privilege before considering any individual application (Correct answer)
- Deny the privilege request until another facility has established precedent
- Allow the provider to perform the procedure under supervision indefinitely
Correct answer: Develop criteria for the new privilege before considering any individual application
Accreditation standards require that privilege criteria be established at the institutional level before evaluating any individual's qualifications for new procedures.
Question 3: Which scenario correctly describes a situation requiring mandatory NPDB reporting by a hospital?
- A provider voluntarily resigns before a formal investigation is opened
- A physician's clinical privileges are reduced for more than 30 days following a professional review action (Correct answer)
- A provider's temporary privileges expire at the end of the standard period
- A provider fails to complete their recredentialing application on time
Correct answer: A physician's clinical privileges are reduced for more than 30 days following a professional review action
Hospitals must report to the NPDB when a practitioner's clinical privileges are reduced, restricted, or revoked for more than 30 days following a professional review action.
Question 4: What is the accreditation significance of verifying a provider's work history for the past five to ten years during credentialing?
- It is required only for applicants who have gaps in their employment
- It helps identify any unexplained gaps that may indicate disciplinary issues or performance concerns (Correct answer)
- It replaces the need for primary source verification of education
- It is a billing compliance requirement rather than a credentialing standard
Correct answer: It helps identify any unexplained gaps that may indicate disciplinary issues or performance concerns
Reviewing work history helps uncover unexplained gaps that may signal disciplinary actions, substance abuse treatment, or other concerns requiring further inquiry.
Question 5: Under NCQA standards, what is the maximum time allowed between a practitioner's recredentialing decisions to maintain continuous network participation?
- 12 months
- 24 months (Correct answer)
- 36 months
- 48 months
Correct answer: 24 months
NCQA requires health plans to recredential network practitioners at least every 24 months (two years) to maintain their active participation status.
Question 6: A credentialing specialist receives a primary source verification response indicating a provider's license is 'under investigation.' What is the appropriate compliance action?
- Treat the license as valid and proceed with credentialing
- Place the application on hold and notify the credentials committee of the finding (Correct answer)
- Deny the application immediately without committee review
- Request the provider submit an explanation and proceed if satisfactory
Correct answer: Place the application on hold and notify the credentials committee of the finding
An active license investigation is a material adverse finding that must be disclosed to and reviewed by the credentials committee before any credentialing decision.
Question 7: Which accreditation standard concept allows a health plan to rely on another accredited organization's credentialing without duplicating the full process?
- Deemed status
- Delegated credentialing (Correct answer)
- Reciprocal privileging
- Credentialing by proxy
Correct answer: Delegated credentialing
Delegated credentialing allows a health plan to formally transfer credentialing responsibilities to another organization, subject to ongoing oversight and audit requirements.
CPCS Accreditation Standards and Compliance 5
Under CMS Conditions of Participation, which practitioner category is explicitly required to be credentialed and privileged by the hospital medical staff?