CPCS Regulatory Compliance & Verification Procedures 5

Question 1

Which regulation requires health plans to notify practitioners of their right to correct erroneous information before a credentialing decision is made?

Accepted Answer

NCQA credentialing standards requiring notification and appeal rights

Answer

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:

Accepted Answer

A written statement of the reasons for denial and an opportunity for hearing or appeal

Answer

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?

Accepted Answer

Requiring all required credentialing elements before processing an application

Answer

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?

Accepted Answer

Credentialing information is generally exempt from HIPAA as it relates to the practitioner, not the patient

Answer

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?

Accepted Answer

NCQA CVO Certification, which indicates the CVO meets NCQA's standards for performing specific verification functions

Answer

NCQA offers CVO Certification to organizations that perform credentialing functions on behalf of health plans, recognizing compliance with NCQA standards.

(CPCS) Certified Professional Credentialing Specialist Practice Test

(CPCS) Certified Professional Credentialing Specialist Practice Test

CPCS Regulatory Compliance & Verification Procedures 5