CPCS Regulatory Compliance & Verification Procedures 5 — Questions and Answers
Question 1: Which regulation requires health plans to notify practitioners of their right to correct erroneous information before a credentialing decision is made?
- NCQA credentialing standards requiring notification and appeal rights (Correct answer)
- The Fair Credit Reporting Act (FCRA)
- The Americans with Disabilities Act (ADA)
- CMS Conditions of Participation §482.12
Correct answer: NCQA credentialing standards requiring notification and appeal rights
NCQA standards require that practitioners be notified of information that may result in a negative credentialing decision and given an opportunity to correct it.
Question 2: A credentialing committee votes to deny privileges based on quality concerns. Under due process requirements, the practitioner is entitled to:
- A written statement of the reasons for denial and an opportunity for hearing or appeal (Correct answer)
- An immediate second review by an external credentialing body
- Automatic reinstatement pending state board review
- Transfer to another facility for credentialing evaluation
Correct answer: A written statement of the reasons for denial and an opportunity for hearing or appeal
Fair hearing and appeal rights are fundamental due process protections that must be offered when adverse credentialing decisions are made.
Question 3: The Sam's Club rule in credentialing refers to which of the following practices?
- Requiring all required credentialing elements before processing an application (Correct answer)
- Offering provisional privileges to all new applicants regardless of background
- Waiving primary source verification for low-risk practitioners
- Accepting credentials from peer-reviewed organizations without verification
Correct answer: Requiring all required credentialing elements before processing an application
The 'Sam's Club rule' concept in credentialing means no application moves forward until all required verifications and elements are present.
Question 4: Under HIPAA, how does the Privacy Rule affect the credentialing process?
- Credentialing information is generally exempt from HIPAA as it relates to the practitioner, not the patient (Correct answer)
- All credentialing documents must be encrypted under HIPAA Security Rule
- Credentialing committees must obtain patient consent before reviewing quality data
- Malpractice history is classified as protected health information under HIPAA
Correct answer: Credentialing information is generally exempt from HIPAA as it relates to the practitioner, not the patient
HIPAA's Privacy Rule governs protected health information about patients; credentialing information about practitioners is not PHI and is not covered by HIPAA.
Question 5: Which type of credentialing verification organization (CVO) certification is recognized by NCQA?
- NCQA CVO Certification, which indicates the CVO meets NCQA's standards for performing specific verification functions (Correct answer)
- Joint Commission CVO Accreditation
- CMS CVO Certification through the Conditions of Participation
- URAC CVO Designation for managed care organizations
Correct answer: NCQA CVO Certification, which indicates the CVO meets NCQA's standards for performing specific verification functions
NCQA offers CVO Certification to organizations that perform credentialing functions on behalf of health plans, recognizing compliance with NCQA standards.
Question 6: A practitioner's license is flagged as 'license under probation with restrictions' by the state board. The credentialing committee should:
- Evaluate whether the restrictions are compatible with the privileges requested before making a determination (Correct answer)
- Automatically deny all privileges until the probation is lifted
- Grant limited privileges without reviewing the specific restrictions
- Table the application indefinitely pending resolution of the probation
Correct answer: Evaluate whether the restrictions are compatible with the privileges requested before making a determination
The committee must review the specific terms of the probation to determine if the restrictions are compatible with the privileges being requested.
Question 7: Which element distinguishes 'focused professional practice evaluation' (FPPE) from 'ongoing professional practice evaluation' (OPPE)?
- FPPE is triggered by a specific concern or new privilege request, while OPPE is continuous routine monitoring (Correct answer)
- FPPE is required only for initial appointments while OPPE applies at re-credentialing
- FPPE involves external peer review while OPPE uses internal data only
- FPPE is mandated by CMS while OPPE is a TJC-only requirement
Correct answer: FPPE is triggered by a specific concern or new privilege request, while OPPE is continuous routine monitoring
FPPE is a time-limited focused evaluation triggered by a new privilege, a concern about performance, or a specific event, while OPPE is continuous routine monitoring.
CPCS Regulatory Compliance & Verification Procedures 5
Which regulation requires health plans to notify practitioners of their right to correct erroneous information before a credentialing decision is made?