CPCS Credentialing Information Management 2 — Questions and Answers
Question 1: A credentialing specialist receives a provider's application with a gap in employment history from 2019 to 2021. What is the most appropriate next step?
- Approve the application assuming the gap is insignificant
- Request a written explanation from the provider for the gap (Correct answer)
- Deny the application due to incomplete employment history
- Contact the state licensing board directly about the gap
Correct answer: Request a written explanation from the provider for the gap
CPCS standards require that all employment gaps be explained in writing by the provider before the application can be processed.
Question 2: Which document type is considered primary source verification for a provider's medical education?
- A notarized copy of the diploma provided by the applicant
- A letter from the residency program director
- Direct written confirmation from the medical school's registrar (Correct answer)
- The provider's curriculum vitae listing educational history
Correct answer: Direct written confirmation from the medical school's registrar
Primary source verification requires confirmation directly from the originating institution, such as the medical school registrar.
Question 3: A hospital's credentialing database shows a physician's DEA registration expiring in 30 days. What action should the credentialing specialist take?
- Wait until after expiration to notify the provider
- Send an automated renewal reminder to the provider immediately (Correct answer)
- Revoke the provider's privileges pending renewal
- Notify the medical staff office only after expiration
Correct answer: Send an automated renewal reminder to the provider immediately
Proactive expiration tracking and timely notifications are essential credentialing information management functions to prevent lapses.
Question 4: Under HIPAA, who is authorized to access a provider's credentialing file containing peer reference letters?
- Any hospital department head upon request
- Only those with a legitimate need-to-know role in the credentialing process (Correct answer)
- All members of the medical staff committee
- Insurance companies performing routine audits
Correct answer: Only those with a legitimate need-to-know role in the credentialing process
Access to credentialing files must be restricted to individuals with a documented, role-based need to know.
Question 5: A credentialing specialist discovers that a provider's board certification lapsed two years ago and was never renewed. What is the correct action if board certification is a condition of privileges?
- Grant a six-month grace period before taking action
- Immediately refer the matter to the medical staff office or appropriate committee (Correct answer)
- Update the file and inform the provider at next reappointment
- Remove the board certification requirement from the provider's file
Correct answer: Immediately refer the matter to the medical staff office or appropriate committee
When a required credential lapses, the credentialing specialist must escalate immediately to the appropriate authority per medical staff bylaws.
Question 6: Which of the following best describes the purpose of a credentialing information management system's audit trail feature?
- To generate billing codes for credentialing services
- To track who accessed or modified credentialing records and when (Correct answer)
- To automatically renew expiring provider licenses
- To compile provider satisfaction surveys
Correct answer: To track who accessed or modified credentialing records and when
Audit trails document all access and modifications to credentialing records, supporting accountability and regulatory compliance.
Question 7: A provider applies for privileges at a new facility while their current privileges at another facility are under investigation. Which database should be queried to detect this situation?
- The Centers for Medicare & Medicaid Services (CMS) enrollment database
- The National Practitioner Data Bank (NPDB) (Correct answer)
- The American Medical Association physician finder
- The state department of health licensing database only
Correct answer: The National Practitioner Data Bank (NPDB)
The NPDB contains reports of adverse actions, investigations, and malpractice payments that must be queried during credentialing.
CPCS Credentialing Information Management 2
A credentialing specialist receives a provider's application with a gap in employment history from 2019 to 2021.
What is the most appropriate next step?