CPCS Knowledge 5 — Questions and Answers
Question 1: Which URAC credentialing standard specifically addresses the time frame within which an organization must complete re-credentialing?
- URAC CR 1
- URAC CR 6 (Correct answer)
- URAC CR 12
- URAC CR 20
Correct answer: URAC CR 6
URAC CR 6 addresses re-credentialing cycle time requirements, specifying that re-credentialing must be completed within 36 months.
Question 2: What is the purpose of a 'tail coverage' endorsement on a claims-made malpractice policy?
- To extend coverage backward to cover incidents before the policy's retroactive date
- To cover claims filed after the policy expires for incidents that occurred during the policy period (Correct answer)
- To provide additional coverage limits above the base policy
- To cover the practitioner's employees under the same policy
Correct answer: To cover claims filed after the policy expires for incidents that occurred during the policy period
Tail coverage (extended reporting endorsement) covers claims submitted after a claims-made policy ends, as long as the incident occurred while the policy was active.
Question 3: Which body has authority to exclude practitioners from participating in Medicare and Medicaid programs?
- State Department of Health
- Office of Inspector General (OIG), HHS (Correct answer)
- Centers for Medicare and Medicaid Services (CMS) directly
- National Practitioner Data Bank administrators
Correct answer: Office of Inspector General (OIG), HHS
The OIG has statutory authority to exclude individuals and entities from Medicare, Medicaid, and other federal healthcare programs.
Question 4: A credentialing file is considered 'complete' when which condition is met?
- The practitioner has submitted all required application documents
- All required primary source verifications have been received and the application is ready for committee review (Correct answer)
- The credentials committee has reviewed the application
- The governing board has approved the practitioner's privileges
Correct answer: All required primary source verifications have been received and the application is ready for committee review
A complete credentialing file means all primary source verifications have been returned and all required documentation is on hand, making the file ready for committee review.
Question 5: Under NCQA standards, which practitioner type is exempt from credentialing requirements for health plans?
- Chiropractors providing network services
- Acupuncturists providing covered benefits
- Practitioners providing only administrative services with no direct patient care (Correct answer)
- Nurse practitioners with prescribing authority
Correct answer: Practitioners providing only administrative services with no direct patient care
NCQA exempts practitioners who perform only administrative or non-clinical roles from credentialing requirements because they provide no direct patient care.
Question 6: A practitioner's DEA registration is in a state different from the state where they are applying for clinical privileges. What should the credentialing specialist do?
- Approve the application since DEA registrations are federally issued and valid nationwide
- Request the practitioner obtain a DEA registration in the state of practice before the file advances (Correct answer)
- Waive the DEA requirement if the practitioner is not prescribing controlled substances
- Report the discrepancy to the NPDB immediately
Correct answer: Request the practitioner obtain a DEA registration in the state of practice before the file advances
DEA registrations are state-specific; a practitioner must hold a DEA registration for the state in which they will be prescribing controlled substances.
Question 7: Which element distinguishes 'Focused Professional Practice Evaluation (FPPE)' from 'Ongoing Professional Practice Evaluation (OPPE)'?
- FPPE is conducted annually while OPPE is triggered by specific events
- FPPE is a time-limited evaluation triggered by concerns or new privileges; OPPE is a continuous performance monitoring process (Correct answer)
- FPPE applies only to new practitioners while OPPE applies only to existing staff
- FPPE uses peer review while OPPE relies exclusively on administrative data
Correct answer: FPPE is a time-limited evaluation triggered by concerns or new privileges; OPPE is a continuous performance monitoring process
FPPE is a defined review period triggered by new privileges or identified concerns, while OPPE is the ongoing systematic monitoring of all practitioners' performance over time.
CPCS Knowledge 5
Which URAC credentialing standard specifically addresses the time frame within which an organization must complete re-credentialing?