CPCS Ongoing Monitoring and Audits 5

Question 1

Under NCQA credentialing standards, how frequently must a health plan re-credential its network providers?

Accepted Answer

Every three years

Answer

NCQA standards require health plans to recredential network practitioners at least every three years.

Question 2

A credentialing coordinator notices that a provider's malpractice carrier has downgraded the policy limits below the organization's minimum threshold. Under ongoing monitoring, what is the CORRECT response?

Accepted Answer

Notify the provider and require evidence of coverage meeting the minimum threshold within a defined timeframe

Answer

When coverage falls below minimum thresholds, the provider must be notified and given a defined window to remedy the deficiency before privileges are affected.

Question 3

Which of the following best describes the concept of 'continuous monitoring' in modern credentialing programs?

Accepted Answer

Using automated, real-time or near-real-time alerts from databases to flag credential changes as they occur

Answer

Continuous monitoring uses automated database connections to generate alerts when licensure, exclusion, or sanction data changes, enabling immediate response.

Question 4

A hospital's credentials committee receives an OPPE report showing a hospitalist's mortality rate is a statistical outlier. The committee must take action under which principle?

Accepted Answer

The corporate negligence doctrine requiring hospitals to monitor and act on known competency concerns

Answer

The corporate negligence doctrine holds hospitals directly liable for failing to act on known practitioner competency concerns identified through monitoring.

Question 5

When performing an ongoing monitoring audit, a credentialing specialist finds that a provider who lists a DEA registration has a specialty inconsistent with controlled substance prescribing. What is the best next step?

Accepted Answer

Flag the inconsistency for medical staff leadership review to determine if the DEA registration is clinically appropriate for the granted privileges

Answer

Clinical appropriateness of credentials relative to granted privileges is a medical staff leadership determination, not a unilateral credentialing staff decision.

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS Ongoing Monitoring and Audits 5