CPCS Credentialing Processes & Accreditation Standards 5 — Questions and Answers
Question 1: Under NCQA credentialing standards, which of the following must be re-verified at recredentialing?
- Medical school transcripts only
- Current licensure, malpractice history, and NPDB query (Correct answer)
- Employment history only
- Personal references only
Correct answer: Current licensure, malpractice history, and NPDB query
At recredentialing, NCQA requires re-verification of current licensure, malpractice history, and a new NPDB query, among other elements.
Question 2: A credentials committee discovers that a physician misrepresented his fellowship training on his application. This constitutes grounds for:
- Automatic renewal of privileges without further review
- Immediate suspension or denial and potential NPDB reporting (Correct answer)
- A confidential warning with no further action
- Referral to the state pharmacy board
Correct answer: Immediate suspension or denial and potential NPDB reporting
Falsification or misrepresentation on a credentialing application is a serious violation that can result in denial or revocation of privileges and mandatory NPDB reporting.
Question 3: Which standard body requires health plans to credential both MD/DO physicians and non-physician practitioners (NPPs) under the same standards?
- The Joint Commission
- NCQA (Correct answer)
- AAAHC
- State insurance departments
Correct answer: NCQA
NCQA credentialing standards apply to both physician and non-physician practitioners, ensuring consistent verification for all licensed independent practitioners.
Question 4: What is the significance of a 'clean claims' provision in a provider contract related to credentialing?
- It allows providers to bypass credentialing if claims are submitted electronically
- It links timely claims payment to completion of the credentialing process (Correct answer)
- It waives primary source verification for in-network providers
- It exempts providers from NPDB reporting requirements
Correct answer: It links timely claims payment to completion of the credentialing process
Clean claims provisions establish that claims submitted by a provider will only be processed after credentialing is complete, linking payment to credentialing status.
Question 5: Which element of the credentialing process is designed to assess a provider's current physical and mental ability to perform clinical duties?
- Attestation of health status on the application (Correct answer)
- Primary source verification of medical school diploma
- NPDB query results
- OIG exclusion check
Correct answer: Attestation of health status on the application
The attestation of health status, signed by the applicant, addresses whether the provider can perform the essential functions of the requested privileges.
Question 6: A credentialing specialist receives a query from a hospital requesting verification of a provider's current staff status. Under NPDB regulations, the hospital must have which of the following to make this query?
- The provider's written authorization
- An active credentialing file for the provider (Correct answer)
- A signed delegation agreement
- A valid CVO certification
Correct answer: An active credentialing file for the provider
Hospitals may query the NPDB about a practitioner only when they have an active credentialing or privileging file open for that individual.
Question 7: Which credentialing model allows a provider credentialed by one entity to be recognized by another participating entity without full re-credentialing?
- Provisional credentialing
- Delegated credentialing
- Reciprocal credentialing / mutual recognition (Correct answer)
- Temporary privileges
Correct answer: Reciprocal credentialing / mutual recognition
Reciprocal or mutual recognition credentialing models allow participating organizations to accept another entity's credentialing determination, reducing duplicative verification.
CPCS Credentialing Processes & Accreditation Standards 5
Under NCQA credentialing standards, which of the following must be re-verified at recredentialing?