CPCS Data Management & Documentation Practices 5 — Questions and Answers
Question 1: A credentialing specialist receives a faxed license verification that shows a provider's license is in 'probationary' status. The IMMEDIATE next step is to:
- Remove the provider from the schedule pending investigation
- Notify the credentialing committee and medical staff leadership per policy (Correct answer)
- Contact the state board to confirm the probationary conditions
- Place a hold on the provider's billing
Correct answer: Notify the credentialing committee and medical staff leadership per policy
Notification to the credentialing committee and leadership triggers the established policy process for handling adverse licensure findings.
Question 2: Which element distinguishes a 'focused' professional practice evaluation (FPPE) file from a standard credentialing file?
- FPPE files contain only malpractice history
- FPPE files document performance data collected during a defined evaluation period for new or expanded privileges (Correct answer)
- FPPE files are maintained by risk management rather than credentialing
- FPPE files replace the need for peer references
Correct answer: FPPE files document performance data collected during a defined evaluation period for new or expanded privileges
FPPE is a time-limited, defined evaluation of a practitioner's performance when new privileges are granted or concerns arise, distinct from routine credentialing files.
Question 3: A hospital uses an automated credentialing system that flags incomplete applications. A provider submits an application missing three required attestation signatures. The system should:
- Auto-approve the application and request signatures retroactively
- Return the application to the provider with specific deficiency notices (Correct answer)
- Forward the incomplete application to the committee with a deficiency note
- Assign a credentialing specialist to obtain signatures via phone
Correct answer: Return the application to the provider with specific deficiency notices
Returning the application with specific deficiency notices ensures the provider completes all requirements before the file enters the review pipeline.
Question 4: Which URAC standard specifically addresses the requirement for a credentialing organization to maintain a written confidentiality policy for credentialing information?
- CR 1 – Network Management
- CR 4 – Confidentiality (Correct answer)
- CR 7 – Recredentialing
- CR 12 – Appeals
Correct answer: CR 4 – Confidentiality
URAC CR 4 requires credentialing organizations to have a written confidentiality policy governing the protection of credentialing information.
Question 5: When a credentialing specialist cannot obtain primary source verification of a license because the issuing board has closed, the BEST documented alternative is:
- Accept the provider's self-attestation as sufficient
- Document the attempt and obtain verification from a recognized equivalent source or state archive (Correct answer)
- Deny the application pending licensure in another state
- Request that the provider obtain a duplicate license
Correct answer: Document the attempt and obtain verification from a recognized equivalent source or state archive
When a primary source is unavailable, thorough documentation of the attempt plus verification from an equivalent or archival source is the accepted alternative.
Question 6: A credentialing software system automatically appends a timestamp and user ID each time a record is modified. This feature supports which documentation principle?
- Data minimization
- Auditability (Correct answer)
- Interoperability
- Portability
Correct answer: Auditability
Automatic timestamping and user ID capture create an audit trail that documents who changed what and when, supporting record accountability.
Question 7: A provider's application reveals a malpractice settlement that was not disclosed on the initial application submitted two years ago. This discrepancy represents a potential issue of:
- Credential fraud requiring immediate termination
- Material misrepresentation warranting investigation per policy (Correct answer)
- Clerical error that can be corrected with an addendum
- Statute of limitations expiration negating any concern
Correct answer: Material misrepresentation warranting investigation per policy
Undisclosed malpractice settlements are considered material misrepresentation and must be investigated through the organization's established policy process.
CPCS Data Management & Documentation Practices 5
A credentialing specialist receives a faxed license verification that shows a provider's license is in 'probationary' status.
The IMMEDIATE next step is to: