CPCS Provider Enrollment and Payer Credentialing Processes 5

Question 1

What is the purpose of conducting an 'OIG exclusion check' during provider enrollment?

Accepted Answer

To confirm the provider is not banned from participating in federal healthcare programs

Answer

The OIG List of Excluded Individuals/Entities (LEIE) identifies providers and entities banned from participation in Medicare, Medicaid, and other federal healthcare programs due to fraud, abuse, or other violations.

Question 2

A critical access hospital (CAH) is credentialing a telemedicine physician employed by a distant-site hospital. Which accreditation standard allows the CAH to rely on the distant site's credentialing?

Accepted Answer

CMS Conditions of Participation telemedicine credentialing provisions

Answer

CMS Conditions of Participation allow critical access hospitals to grant privileges to telemedicine physicians based on the distant-site hospital's credentialing and privileging decisions under a written agreement.

Question 3

During re-credentialing, a physician discloses a new DUI conviction that occurred 18 months ago. What is the MOST appropriate next step for the credentialing specialist?

Accepted Answer

Refer the disclosure to the credentialing committee for individualized review per established policy

Answer

Criminal convictions disclosed during re-credentialing must be referred to the credentialing committee for individualized review according to the organization's established policies and bylaws.

Question 4

Which term describes the process where a provider is granted temporary practice privileges while full credentialing verification is still in progress?

Accepted Answer

Provisional or temporary privileges

Answer

Provisional or temporary privileges allow a provider to begin practicing while the full credentialing process is completed, typically subject to specific conditions and time limits set by the organization.

Question 5

A payer's contract stipulates a 'most favored nation' (MFN) clause. How does this affect provider enrollment strategy?

Accepted Answer

The provider cannot charge this payer more than the lowest rate given to any other payer

Answer

A most favored nation clause requires the provider to give the contracting payer rates no higher than the lowest rates offered to any other commercial payer, which constrains negotiation flexibility across payer contracts.

(CPCS) Certified Professional Credentialing Specialist Practice Test

(CPCS) Certified Professional Credentialing Specialist Practice Test

CPCS Provider Enrollment and Payer Credentialing Processes 5