CPCS Credentialing Processes & Accreditation Standards 5

Question 1

Under NCQA credentialing standards, which of the following must be re-verified at recredentialing?

Accepted Answer

Current licensure, malpractice history, and NPDB query

Answer

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:

Accepted Answer

Immediate suspension or denial and potential NPDB reporting

Answer

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?

Accepted Answer

NCQA

Answer

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?

Accepted Answer

It links timely claims payment to completion of the credentialing process

Answer

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?

Accepted Answer

Attestation of health status on the application

Answer

The attestation of health status, signed by the applicant, addresses whether the provider can perform the essential functions of the requested privileges.

(CPCS) Certified Professional Credentialing Specialist Practice Test

(CPCS) Certified Professional Credentialing Specialist Practice Test

CPCS Credentialing Processes & Accreditation Standards 5