CPCS Regulatory Compliance & Verification Procedures 3 — Questions and Answers
Question 1: Which accreditation body publishes the URAC Credentialing Standards used by managed care organizations?
- URAC (formerly Utilization Review Accreditation Commission) (Correct answer)
- The Joint Commission (TJC)
- NCQA (National Committee for Quality Assurance)
- ACHC (Accreditation Commission for Health Care)
Correct answer: URAC (formerly Utilization Review Accreditation Commission)
URAC developed and maintains its own credentialing standards for health plans and managed care organizations.
Question 2: Under NCQA standards, which of the following is considered a 'red flag' that requires additional review during the credentialing process?
- A history of professional liability actions exceeding the threshold defined by the organization (Correct answer)
- Completion of residency training more than 10 years ago
- Board certification in a specialty other than the one applied for
- Licensure in more than three states simultaneously
Correct answer: A history of professional liability actions exceeding the threshold defined by the organization
NCQA requires organizations to define thresholds for professional liability history that trigger additional review.
Question 3: What does 'attestation' mean in the context of credentialing applications?
- A practitioner's signed declaration that the information provided is true and complete (Correct answer)
- A primary source's written confirmation of credentials
- A hospital's official approval of clinical privileges
- A credentialing committee's formal vote on an application
Correct answer: A practitioner's signed declaration that the information provided is true and complete
Attestation is the applicant's signed oath affirming the accuracy and completeness of the information provided on the credentialing application.
Question 4: State-mandated credentialing timelines often require health plans to complete the credentialing process within:
- 60 to 180 days depending on the state (Correct answer)
- 30 days maximum
- Up to 365 days
- No specific state mandates exist; it is solely at health plan discretion
Correct answer: 60 to 180 days depending on the state
Most states with credentialing regulations require health plans to complete credentialing within 60–180 days of receiving a complete application.
Question 5: Which organization maintains the CAQH ProView database commonly used in credentialing?
- CAQH (Council for Affordable Quality Healthcare) (Correct answer)
- CMS (Centers for Medicare & Medicaid Services)
- NCQA (National Committee for Quality Assurance)
- AMA (American Medical Association)
Correct answer: CAQH (Council for Affordable Quality Healthcare)
CAQH operates the ProView universal credentialing database that allows providers to submit information once for use by multiple health plans.
Question 6: An organization's credentialing policy requires verification of all licenses for the past 5 years. A practitioner was licensed in a state where they no longer practice. What action is required?
- Verify the historical license even if it is no longer active (Correct answer)
- Skip verification since the license is no longer active
- Request only verification of currently active licenses
- Report the lapsed license to the state medical board
Correct answer: Verify the historical license even if it is no longer active
Credentialing policies requiring 5-year history verification necessitate confirming all licenses held during that period, active or inactive.
Question 7: When a telemedicine provider seeks credentials to practice across multiple states, which regulatory framework primarily governs their licensure?
- Each individual state's licensing laws where the patient is located (Correct answer)
- The federal Interstate Compact for telemedicine only
- Only the state where the provider is physically located
- CMS telehealth waivers that supersede state law
Correct answer: Each individual state's licensing laws where the patient is located
Telemedicine practice is governed by the laws of the state where the patient is located, requiring licensure in each patient-state.
CPCS Regulatory Compliance & Verification Procedures 3
Which accreditation body publishes the URAC Credentialing Standards used by managed care organizations?