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CPCS - Certified Provider Credentialing Specialist
Terms in this set (96)
Are limitations of the clinical privileges of a psychiatrist for more than 30 days reportable to the NPDB?
According to TJC, who may amend the medical staff bylaws?
Failure to meet the established qualifications and criteria for appointment should be reported to whom?
NCQA requires the MCO to obtain a minimum of how may years of work history?
According to the NCQA what policy must an organization have in place to obtain approval to enter into a delegated agreement?
How often does the OIG report to the NPDB?
When must hospitals query the NPDB?
Initial appointment, granting of privileges, every two years.
NCQA requires verifications must be less than how many days old?
What is the verification time limit on malpractice history according to the NCQA?
Time limited credential must be verified by the CVO with how may days prior to submission to the client?
According the AAAHC, for initial appointments, in addition to licensure and education, what verification is required?
Experience and hospital affiliations.
What accreditation body states "The NPDB is an acceptable source for sanctions or limitations on licensure, Medicaid/ Medicare sanctions and malpractice history?
Who is required to query the NPDB?
Is disciplinary action taken against the license of a dentist reportable to the NPDB?
Under HCQIA a hospital failure to report an adverse privilege action lasting longer than 30 days may cause the organization to lose HCQIA immunity for how many years?
According to NCQA, verification of Medicare/Medicaid sanctions can be queried by any of what sources?
AMA, FSMB, HIPDB, OIG Sanctions Report, NPDB, State Agency
According to NCQA, how often must an organization conduct an audit of the credentialing process delegated to another organization?
How far back does TJC require evaluation of malpractice history?
Back to medical school
According to TJC, what source may be used to evaluate malpractice history?
Is an internet verification from a website not contracted by the primary source that attests to the accuracy and timeliness of the information considered a complete verification by NCQA?
What accreditation bodies require privileges to be distributed to essential department personnel?
TJC and NCQA do not require criminal background checks.
Is a payment made by an insurance company reportable to the NPDB?
Who is the best person to consult when releasing adverse information in a verification request from another organization?
According to CMS, who in the organization may make decisions regarding approval of credentialing applications?
According to the NCQA what providers are NOT required to be credentialed when working in an independent relationship?
Locums Tenens, hospital based practitioners
How many peer references does HFAP require at initial appointment?
Denial of a medical license application by a state medical board is not reportable to the NPDB. (T/F)
Which two accreditors state a hospital may not rely solely on board certification when considering a practitioner for medical staff membership?
According to TJC and HFAP, name four approved sources for PSV for medical education.
Medical School, AMA, AOA, ECFMG
According to NCQA, practitioners must be notified of credentialing decisions within how many days?
The DHHS mails a copy of the NPDB report to the named provider. If the provider wishes to dispute the reports accuracy, the provide has how many days to do so?
According to URAC, within how many days must the practitioner be notified of credentialing decisions?
How many days does a practitioner have to dispute an NPDB report accuracy?
Which accrediting body requires five year verification of malpractice history?
What is the commonly used source for verifying malpractice history?
According to the Joint Commission, a fair hearing and appeals process as described in the medical staff bylaws is available to whom?
Medical staff members, non-members holding clinical privileges
Only the highest of training must be verified according to the NCQA. (T/F)
According to TJC, a peer recommendation should address what six competencies?
Medical knowledge, Technical and clinical skills, Clinical judgement, Interpersonal skills, Communication skills, Professionalism
Telemedicine - according to TJC, what two options are available for credentialing at the originating site?
Full credentialing, use of the distant site credentialing
A hospital that does not query the databank as required by HCQIA is what?
Legally liable for knowledge of any information reported.
According to TJC, OPPE should be performed on whom?
All privileged practitioners
According to TJC, who can provide confirmation of an applicant's health status?
Director of post graduate training program, Chief of another hospital where applicant holds privileges
According to the NCQA, any gap in personal history greater than how long must be clarified in writing?
According to TJC, what two verifications must be performed before granting of privileges to satisfy an urgent patient care need?
Current licensure, current competence
According to TJC, what committee is required to review and make recommendations regarding credentialing applications?
What document is best used to evaluate if an applicant meets an organizations minimum credentialing applications?
Name an essential source when developing a peer review policy?
According to NCQA, what requires ongoing monitoring between credentialing cycles?
The HCQIA was passed into law in what year?
HCQIA peer review protections apply to peer review of what?
According to URAC, the credentialing applications must include what?
Release of information
What is the NCQA's requirement for history of felonies on applications and reappointment?
The application requires a statement from the applicant
According to TJC, what is required to be verified at the time of expiration?
According to NCQA standards, if deficiencies are noted during a site visit an action plan must be developed. The office site must implement the plan within how many months of the initial visit?
If the physician is notified of an adverse recommendation and requests a hearing what is required in the notice?
Place, time and date, hearing date within 30 days from date of notice, list of witnesses
What is the time limit on PSV of current licensure according to NCQA?
When an applicant for membership or privileges with a clean application is awaiting approval of MEC and the governing body, temporary privileges may be granted for a limited time not to exceed how many days?
Medical malpractice payers may query the NPDB. (T/F)
Name two sources of verification of education of a chiropractor according to NCQA.
Chiropractic college, state licensing agency
TJC requires PSV of board certification. (T/F)
According to URAC, what must be verified using primary source?
State licensure, highest level of education
According to TJC, who has the ultimate authority in credentialing decisions?
According to NCQA, a provisional period is granted for no longer than how many days?
According to NCQA, what verification is required before provisional credentialing is permitted?
Current license, five-year malpractice history
NCQA requires an attestation of good health and competence to perform essential functions. How is this achieved?
Within how many days must a medical malpractice payer report payment resulting from written claim or judgment to the NPDB & state licensing board?
According to TJC, appointment or reappointment to the medical staff and granting, renewal or revision of clinical privileges are made for a period of how long?
No more than two years
According to NCQA how long is a verification of work history valid?
What came first HIPDB or NPDB?
According to NCQA, how long is the signature on the attestation good for?
According to NCQA, how long is the signature on the attestation good for CVO's?
What is the verification time limit for verification of Medicare/Medicaid sanctions according to NCQA?
How often does AAAHC require recredentialing?
At least every three years
According to URAC, who should oversee the clinical aspects of the credentialing program within the organization?
Senior clinical staff person
Name three sources of verification of education of a dentist according to NCQA.
Dental school, specialty board, state licensing board
NCQA requires MCO's to recredential practitioners at least every___________?
HFAP is commonly known as what?
AOA, an osteopathic organization
No accreditation body requires verification of malpractice insurance. (T/F)
According to TJC, which of the following should be used to verify current competence? Board certification, malpractice face sheet, hospital verification or patient complaint record.
According to NCQA, who has ultimate authority in credentialing decisions?
Credentials committee and medical director if it is a clean file
What two entities does EMTALA not apply?
Military and Shriners
Do TJC or NCQA require date stamping?
What does NCQA require in place of date stamping?
Organizations must demonstrate the credentialing information was present and current at the time of the credentialing decision.
Name seven sources for verifications of highest level of education of an MD or DO according to NCQA.
Medical school, AMA, AOA, ECFMG, Assoc of schools for HC providers, state licensing board, ABMS if board certified.
According to NCQA application PSV must be dated within how many days of the credentialing decision?
According to NCQA what credential must be verified at the time or recredentialing?
Current malpractice, state license
According to TJC, when must a license be verified?
Initial appointment, reappointment, granting of privileges, expiration
NCQA requires PSV of board certification. What sources can be used?
ABMS, AOA, AMA, specialty board, state licensing board
How long is PSV of board certification good for according to NCQA?
What are some sources that can be used to determine which procedures should be performed by which specialty?
Specialty board, white papers
How many days must adverse actions or payouts be reported by malpractice payers?
How many days must adverse actions or payouts be reported by a state licensing board?
How many days must adverse actions or payouts be reported by hospitals and health care entities?
How many days must adverse actions or payouts be reported by professional societies?
Name three sources of education of a podiatrist according to NCQA.
Medical school, specialty board, state licensing board
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