CPCS Credentialing Processes & Accreditation Standards 3 — Questions and Answers
Question 1: When a health plan delegates credentialing to a medical group, the health plan retains responsibility for which of the following?
- Performing all primary source verifications
- Oversight and final approval of the delegation arrangement (Correct answer)
- Issuing provider contracts
- Collecting provider application fees
Correct answer: Oversight and final approval of the delegation arrangement
Even when credentialing is delegated, the health plan retains ultimate accountability and must maintain oversight of the delegated entity's compliance.
Question 2: A physician applies for privileges in a specialty she has not practiced in two years. Which criterion is MOST relevant to the credentials committee?
- Board certification status only
- Recency and volume of relevant clinical activity (Correct answer)
- Number of malpractice suits filed
- State license issue date
Correct answer: Recency and volume of relevant clinical activity
Current clinical competence is demonstrated through recent and sufficient volume of practice in the relevant specialty area.
Question 3: Which element is NOT typically verified through primary source verification during initial credentialing?
- Medical school graduation
- Current state license
- Provider's personal references (Correct answer)
- Board certification status
Correct answer: Provider's personal references
Personal references are collected but are not obtained directly from a primary (original) source — they are peer references solicited from individuals named by the provider.
Question 4: URAC's credentialing standards most directly apply to which type of organization?
- Acute care hospitals
- Health plans and managed care organizations (Correct answer)
- State medical boards
- Pharmacy benefit managers only
Correct answer: Health plans and managed care organizations
URAC accredits health plans and managed care organizations and sets credentialing standards specifically applicable to those entities.
Question 5: What is the maximum timeframe NCQA allows for completing the initial credentialing process once an application is deemed complete?
- 60 days
- 90 days
- 120 days
- 180 days (Correct answer)
Correct answer: 180 days
NCQA standards require organizations to complete the credentialing process within 180 days of receiving a complete application.
Question 6: Which query is mandatory when credentialing a DEA-registered practitioner?
- State prescription monitoring program only
- National Practitioner Data Bank (NPDB) (Correct answer)
- Federation of State Medical Boards (FSMB) only
- Medicare Exclusion List (OIG) only
Correct answer: National Practitioner Data Bank (NPDB)
The NPDB must be queried for all practitioners applying for clinical privileges, regardless of DEA registration status.
Question 7: A credentialing file is missing a reference letter. Under due-diligence standards, what should the specialist do?
- Approve the application with a note in the file
- Contact the provider to obtain the missing reference (Correct answer)
- Deny the application immediately
- Proceed to the credentials committee without the letter
Correct answer: Contact the provider to obtain the missing reference
The specialist must attempt to obtain all required documentation, including following up with the provider to secure the missing reference.
CPCS Credentialing Processes & Accreditation Standards 3
When a health plan delegates credentialing to a medical group, the health plan retains responsibility for which of the following?