CPCS Provider Enrollment and Payer Credentialing Processes 3

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?

Accepted Answer

Request a written explanation from the provider detailing the gap period

Answer

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?

Accepted Answer

It serves as a centralized repository for provider credentialing data used by multiple payers

Answer

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?

Accepted Answer

The provider may see Medicare patients but must accept limiting charges, not full assignment

Answer

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?

Accepted Answer

The certifying specialty board directly (Primary Source Verification)

Answer

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?

Accepted Answer

A claim submitted with all required data elements and no deficiencies that would prevent processing

Answer

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.

(CPCS) Certified Professional Credentialing Specialist Practice Test

(CPCS) Certified Professional Credentialing Specialist Practice Test

CPCS Provider Enrollment and Payer Credentialing Processes 3