CPCS Primary Source Verification 4 — Questions and Answers
Question 1: A provider's application reveals training at a foreign hospital not accredited by a recognized U.S. body. What is the most appropriate verification method?
- Accept the provider's transcript as sufficient
- Contact the foreign hospital directly and use a credentialing verification organization (CVO) if needed (Correct answer)
- Deny privileges since international training cannot be verified
- Rely solely on ECFMG verification
Correct answer: Contact the foreign hospital directly and use a credentialing verification organization (CVO) if needed
Direct contact with the institution or use of a qualified CVO experienced in international verification is appropriate for foreign training verification.
Question 2: What does 'continuous enrollment' verification mean in managed care credentialing?
- Confirming a provider has been enrolled with Medicare continuously
- Verifying that malpractice coverage has been maintained without lapses (Correct answer)
- Ensuring the provider has practiced without interruption
- Confirming the provider is continuously enrolled in a health plan network
Correct answer: Verifying that malpractice coverage has been maintained without lapses
Continuous enrollment verification in malpractice insurance means confirming there are no gaps in professional liability coverage.
Question 3: Which of the following is an example of a 'sentinel event' flag that would trigger mandatory review during primary source verification?
- A license issued in a different state than current practice
- A malpractice payment reported to the NPDB within the past five years (Correct answer)
- Board certification that expires within six months
- A medical school diploma from a Caribbean institution
Correct answer: A malpractice payment reported to the NPDB within the past five years
An NPDB malpractice payment report is a sentinel event that requires mandatory disclosure and review by the credentialing committee.
Question 4: A hospital grants temporary privileges to a provider pending completion of primary source verification. Which standard governs this practice?
- CMS Conditions of Participation (Correct answer)
- HIPAA Privacy Rule
- OSHA standards
- State nursing board regulations
Correct answer: CMS Conditions of Participation
CMS Conditions of Participation regulate how hospitals may grant temporary privileges during the credentialing process.
Question 5: Which of the following is a legitimate reason primary source verification may be waived or delegated per accreditation standards?
- The provider is well-known in the community
- The organization uses a NCQA-certified CVO that has already performed verification (Correct answer)
- The provider has been practicing for more than 20 years
- The chief of staff vouches for the provider's credentials
Correct answer: The organization uses a NCQA-certified CVO that has already performed verification
NCQA allows delegation of primary source verification to a certified CVO, which meets the standard without the organization repeating the process.
Question 6: When a discrepancy is found between the dates on a provider's application and those confirmed by a primary source, what is the required action?
- Correct the application without notifying the provider
- Document the discrepancy and request the provider clarify or explain it (Correct answer)
- Immediately disqualify the provider for misrepresentation
- Contact the credentialing committee without informing the provider
Correct answer: Document the discrepancy and request the provider clarify or explain it
Discrepancies must be documented and the provider must be given the opportunity to explain before any determination is made.
Question 7: Which element of primary source verification is specifically required by The Joint Commission (TJC) for all licensed independent practitioners?
- Criminal background check
- Current licensure verification (Correct answer)
- Credit history review
- Insurance utilization review
Correct answer: Current licensure verification
TJC requires verification of current licensure as a core element of primary source verification for all licensed independent practitioners.
CPCS Primary Source Verification 4
A provider's application reveals training at a foreign hospital not accredited by a recognized U.S. body.
What is the most appropriate verification method?