CPCS Regulatory Compliance & Verification Procedures 3

Question 1

Which accreditation body publishes the URAC Credentialing Standards used by managed care organizations?

Accepted Answer

URAC (formerly Utilization Review Accreditation Commission)

Answer

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?

Accepted Answer

A history of professional liability actions exceeding the threshold defined by the organization

Answer

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?

Accepted Answer

A practitioner's signed declaration that the information provided is true and complete

Answer

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:

Accepted Answer

60 to 180 days depending on the state

Answer

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?

Accepted Answer

CAQH (Council for Affordable Quality Healthcare)

Answer

CAQH operates the ProView universal credentialing database that allows providers to submit information once for use by multiple health plans.

(CPCS) Certified Professional Credentialing Specialist Practice Test