CPCS Provider Enrollment and Payer Credentialing Processes 3 — Questions and Answers
Question 1: A credentialing specialist is reviewing a provider's work history and finds an unexplained gap of 8 months. What is the standard best practice?
- Approve the application since gaps under one year are acceptable
- Request a written explanation from the provider detailing the gap period (Correct answer)
- Automatically deny the application due to the incomplete history
- Flag the file but proceed without documentation
Correct answer: Request a written explanation from the provider detailing the gap period
Standard credentialing practice requires providers to account for all gaps in employment or training history of typically 30 days or more, usually through a written explanation.
Question 2: What is the primary function of the CAQH ProView database in the credentialing process?
- It assigns National Provider Identifiers to new providers
- It serves as a centralized repository for provider credentialing data used by multiple payers (Correct answer)
- It processes Medicare enrollment applications on behalf of CMS
- It maintains the national registry of sanctioned providers
Correct answer: It serves as a centralized repository for provider credentialing data used by multiple payers
CAQH ProView is a centralized platform where providers store their credentialing information, which participating payers can then access to streamline the credentialing process.
Question 3: A provider is enrolled with Medicare as a 'non-participating' provider. What does this status mean for Medicare beneficiaries?
- The provider cannot see Medicare patients under any circumstances
- The provider may see Medicare patients but must accept limiting charges, not full assignment (Correct answer)
- The provider is fully excluded from the Medicare program
- The provider accepts Medicare as secondary insurance only
Correct answer: The provider may see Medicare patients but must accept limiting charges, not full assignment
Non-participating providers can still treat Medicare patients but do not accept assignment on all claims; they may charge up to the limiting charge (115% of the non-par fee schedule amount).
Question 4: During initial credentialing, which source is considered the most authoritative for verifying a physician's board certification?
- The provider's curriculum vitae
- The certifying specialty board directly (Primary Source Verification) (Correct answer)
- A letter from the provider's former employer
- The state medical board website
Correct answer: The certifying specialty board directly (Primary Source Verification)
Primary Source Verification (PSV) requires obtaining information directly from the issuing organization, such as the certifying specialty board, which is the gold standard for verifying credentials.
Question 5: What does 'clean claim' mean in the context of provider enrollment and billing?
- A claim that has been paid without any adjustments or denials
- A claim submitted with all required data elements and no deficiencies that would prevent processing (Correct answer)
- A claim from a provider with no prior billing compliance issues
- A claim submitted electronically rather than on paper
Correct answer: A claim submitted with all required data elements and no deficiencies that would prevent processing
A clean claim contains all required data elements, is free from deficiencies, and can be adjudicated by the payer without the need for additional information.
Question 6: Which entity maintains the National Practitioner Data Bank (NPDB) and makes it available for credentialing queries?
- Centers for Medicare and Medicaid Services (CMS)
- Health Resources and Services Administration (HRSA) (Correct answer)
- American Medical Association (AMA)
- The Joint Commission (TJC)
Correct answer: Health Resources and Services Administration (HRSA)
The NPDB is maintained by the Health Resources and Services Administration (HRSA), a division of the U.S. Department of Health and Human Services.
Question 7: A provider group receives a 'withhold' notification from a managed care organization. In credentialing context, what does this typically indicate?
- The provider's enrollment application has been withheld pending verification
- A percentage of reimbursement is being held back pending performance or quality metrics (Correct answer)
- The payer is withholding credentialing approval until malpractice insurance is updated
- The provider's claims are under audit and payment is suspended
Correct answer: A percentage of reimbursement is being held back pending performance or quality metrics
A withhold in managed care refers to a portion of the provider's payment that the MCO holds back and returns (in whole or part) based on meeting quality, utilization, or financial targets.
CPCS Provider Enrollment and Payer Credentialing Processes 3
A credentialing specialist is reviewing a provider's work history and finds an unexplained gap of 8 months.
What is the standard best practice?