CPCS Knowledge 3

Question 1

Which federal law established the Healthcare Integrity and Protection Data Bank (HIPDB), later merged with the NPDB?

Accepted Answer

Health Insurance Portability and Accountability Act (HIPAA) of 1996

Answer

HIPAA created the HIPDB to combat fraud and abuse; it was merged into the NPDB in 2013.

Question 2

A Credentials Verification Organization (CVO) that seeks NCQA certification must demonstrate what key capability?

Accepted Answer

Performing primary source verification according to NCQA's credentialing standards

Answer

NCQA CVO certification requires the CVO to conduct primary source verification processes consistent with NCQA credentialing standards.

Question 3

Under The Joint Commission standards, which committee typically has final authority over clinical privileging decisions?

Accepted Answer

The Governing Board

Answer

While the Medical Executive Committee recommends privileges, TJC standards place ultimate authority for granting, limiting, or revoking privileges with the Governing Board.

Question 4

A practitioner who holds a time-limited license with conditions imposed by the state board should trigger which credentialing action?

Accepted Answer

Further investigation and reporting to the appropriate committee for review

Answer

A conditional or restricted license is a red flag that must be investigated and referred to the credentials or medical executive committee for a determination.

Question 5

What is the significance of the 'clean claims' period in the context of a practitioner's malpractice insurance verification?

Accepted Answer

It is the period without any reported malpractice claims used to assess risk history

Answer

A 'clean claims' period reflects years without malpractice claims, which credentialers use to evaluate a practitioner's liability risk profile.

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS Knowledge 3