CPCS Provider Enrollment and Payer Credentialing Processes 2

Question 1

A provider submits an enrollment application to Medicare and receives a 'development letter.' What does this mean?

Accepted Answer

Additional information or documentation is needed to process the application

Answer

The application has been approved pending a site visit

Answer

The provider has been rejected and must reapply

Answer

The application has been forwarded to a state Medicaid agency

Question 2

Which National Provider Identifier (NPI) type should a solo practitioner use when billing independently?

Accepted Answer

Type 1 NPI as an individual provider

Answer

Type 2 NPI as a subpart of a group

Answer

Type 3 NPI as a specialty-specific identifier

Answer

Either Type 1 or Type 2 at the provider's discretion

Question 3

A hospital-based physician group wants to enroll with a commercial payer. Which document typically outlines the contractual terms including fee schedules?

Accepted Answer

Provider Participation Agreement

Answer

Certificate of Insurance

Answer

CAQH attestation form

Answer

CMS-855I application

Question 4

Under the Medicare enrollment process, what is the purpose of the CMS-855B application?

Accepted Answer

Enrollment of clinics, group practices, and certain other suppliers

Answer

Enrollment of individual physicians and non-physician practitioners

Answer

Enrollment of durable medical equipment suppliers

Answer

Reassignment of Medicare billing to another entity

Question 5

A credentialing specialist discovers a provider's DEA registration has expired. What is the most appropriate immediate action?

Accepted Answer

Notify the provider and place their privileges on hold until renewal is confirmed

Answer

Submit the credentialing file with a note that renewal is pending

Answer

Remove the provider from the medical staff roster permanently

Answer

File a complaint with the state medical board

Question 6

What is 'payer mix' in the context of provider enrollment strategy?

Accepted Answer

The combination of different insurance plans a provider accepts

Answer

The ratio of in-network to out-of-network claims submitted

Answer

The average reimbursement rate across all contracted payers

Answer

The number of payers a credentialing specialist manages simultaneously

Question 7

Which federal program requires providers to enroll before ordering or referring certain items and services for beneficiaries?

Accepted Answer

Medicare

Answer

TRICARE

Answer

CHIP

Answer

FEHB