CPCS MCQ 5 — Questions and Answers
Question 1: Under NCQA credentialing standards, which of the following may be used as an acceptable alternative to primary source verification of board certification?
- A copy of the certificate submitted by the provider
- Verification via the certifying board's online database (Correct answer)
- A letter from the provider's residency program
- A sworn affidavit from the provider
Correct answer: Verification via the certifying board's online database
NCQA accepts verification through a certifying board's publicly available online database as equivalent to primary source verification.
Question 2: Which of the following is a key responsibility of a credentials committee?
- Setting provider reimbursement rates
- Making recommendations on granting, denying, or modifying clinical privileges (Correct answer)
- Negotiating managed care contracts
- Scheduling provider orientation sessions
Correct answer: Making recommendations on granting, denying, or modifying clinical privileges
The credentials committee reviews credentialing files and recommends privilege decisions to the governing body.
Question 3: What does the term 'clean claim' mean in the context of provider credentialing and enrollment?
- A claim submitted without any diagnosis codes
- A claim that can be processed without additional information or investigation (Correct answer)
- A claim submitted on paper rather than electronically
- A claim with a zero balance after patient payment
Correct answer: A claim that can be processed without additional information or investigation
A clean claim contains all required information and can be adjudicated by the payer without additional documentation.
Question 4: A managed care organization delegates credentialing to a hospital. Which element is essential for a compliant delegation agreement?
- The hospital agrees to credential only its own employees
- The MCO retains the right to approve, deny, or rescind privileges (Correct answer)
- The hospital assumes full liability for all credentialing decisions
- The MCO waives all audit rights to reduce administrative burden
Correct answer: The MCO retains the right to approve, deny, or rescind privileges
In delegated credentialing, the MCO must retain oversight authority including the right to approve, deny, or rescind provider participation.
Question 5: Which database should be queried to identify providers sanctioned under Medicare or Medicaid programs?
- NPDB
- SAM.gov Exclusions
- OIG List of Excluded Individuals and Entities (LEIE) (Correct answer)
- FSMB DocInfo
Correct answer: OIG List of Excluded Individuals and Entities (LEIE)
The OIG LEIE specifically identifies individuals and entities excluded from participation in federal healthcare programs including Medicare and Medicaid.
Question 6: A credentialing specialist discovers that a provider's work history contains a gap of 18 months with no explanation. What is the most appropriate action?
- Approve the application and note the gap in the file
- Request a written explanation from the provider for the gap period (Correct answer)
- Automatically deny the application for incomplete history
- Contact the state medical board to investigate the provider
Correct answer: Request a written explanation from the provider for the gap period
Requesting a written explanation for the unexplained gap allows the provider to clarify and ensures the file is complete before a decision is made.
Question 7: Which privileging model grants providers permission to perform specific procedures based on demonstrated training and competency?
- Core privileging
- Delineation of privileges (Correct answer)
- Blanket privileges
- Category-based privileging
Correct answer: Delineation of privileges
Delineation of privileges is the process of specifying exactly which clinical activities a practitioner is authorized to perform based on credentials and competency evidence.
CPCS MCQ 5
Under NCQA credentialing standards, which of the following may be used as an acceptable alternative to primary source verification of board certification?