CPCS Primary Source Verification (PSV) Standards and Procedures 3 — Questions and Answers
Question 1: A practitioner's medical school closed and no successor organization can be found. What is the most appropriate action for the credentialing specialist?
- Waive the PSV requirement entirely since the school no longer exists
- Accept the practitioner's copy of the diploma as sufficient verification
- Research alternative verification sources such as state licensing board records or AMA profiles, document all efforts, and follow organizational policy (Correct answer)
- Automatically deny the application due to inability to verify
Correct answer: Research alternative verification sources such as state licensing board records or AMA profiles, document all efforts, and follow organizational policy
When a primary source is unavailable, credentialing specialists must exhaust alternative sources, document all efforts, and follow organizational policy—which may allow alternative verification pathways.
Question 2: Which scenario represents a failed Primary Source Verification that requires escalation?
- A state licensing board confirms a license is active but notes a prior suspension now lifted
- The ABMS database shows board certification as current and unrestricted
- A training institution cannot confirm that a practitioner completed the residency they claimed on their application (Correct answer)
- A DEA registration is confirmed as valid through the DEA verification portal
Correct answer: A training institution cannot confirm that a practitioner completed the residency they claimed on their application
When a primary source cannot confirm what a practitioner claimed—in this case residency completion—it constitutes a material discrepancy that must be escalated to the credentials committee.
Question 3: What is the required action when a discrepancy is discovered between a practitioner's attestation and Primary Source Verification findings?
- Immediately terminate the application without further investigation
- Ignore minor discrepancies if they do not appear to affect clinical competency directly
- Document the discrepancy and refer the matter to the credentials committee per organizational policy (Correct answer)
- Contact the practitioner to allow correction of the information before any documentation occurs
Correct answer: Document the discrepancy and refer the matter to the credentials committee per organizational policy
Discrepancies found during PSV must be documented and referred to the credentials committee, which holds the authority to determine how such findings affect appointment decisions.
Question 4: Under The Joint Commission standards, which elements must be verified both at initial appointment AND at reappointment?
- Medical school graduation date only
- Current licensure, relevant training or experience, current competence, and ability to perform requested privileges (Correct answer)
- Criminal background checks and malpractice history only
- Medicare and Medicaid enrollment status
Correct answer: Current licensure, relevant training or experience, current competence, and ability to perform requested privileges
TJC requires verification of current licensure, relevant training or experience, current competence, and ability to perform privileges at both initial appointment and every reappointment.
Question 5: A hospital delegates PSV to a Credentials Verification Organization (CVO). Which statement is TRUE regarding the hospital's accountability?
- The hospital has no further credentialing responsibility once a CVO is engaged
- The hospital remains fully accountable for ensuring PSV is completed appropriately and meets accreditation standards (Correct answer)
- The CVO assumes complete legal liability for any errors that occur during verification
- Using a CVO eliminates the need for medical staff committee review of credentials
Correct answer: The hospital remains fully accountable for ensuring PSV is completed appropriately and meets accreditation standards
Even when a CVO performs PSV, the hospital retains ultimate accountability for ensuring that credentialing processes meet all accreditation and regulatory requirements.
Question 6: Which element must be verified through Primary Source Verification for every practitioner seeking privileges, according to CMS Conditions of Participation?
- National Provider Identifier (NPI) number
- A current, valid license to practice in the state (Correct answer)
- Professional liability insurance coverage limits
- Complete employment history for the past 10 years
Correct answer: A current, valid license to practice in the state
CMS Conditions of Participation require hospitals to verify that each practitioner holds a current, valid license as a fundamental prerequisite for granting clinical privileges.
Question 7: Which best describes the role of the National Association Medical Staff Services (NAMSS) in relation to Primary Source Verification standards?
- NAMSS publishes legally binding PSV requirements that supersede Joint Commission standards
- NAMSS provides best practice guidance and position statements to help credentialing professionals conduct and document PSV appropriately (Correct answer)
- NAMSS certifies CVOs to perform PSV on behalf of accredited hospitals
- NAMSS replaces The Joint Commission as the primary accreditation authority for hospital credentialing
Correct answer: NAMSS provides best practice guidance and position statements to help credentialing professionals conduct and document PSV appropriately
NAMSS publishes best practice white papers and position statements that guide credentialing professionals, but these are advisory resources rather than legally binding regulatory standards.
CPCS Primary Source Verification (PSV) Standards and Procedures 3
A practitioner's medical school closed and no successor organization can be found.
What is the most appropriate action for the credentialing specialist?