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CMOM Module 5 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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CMOM Module 5 Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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CMOM Module 5 Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100%Verified
Credentialing - verifies that a physician meets standards through the review of license, experience,
certification, education, training, malpractice and adverse clinical occurrences, clinical judgement and
character via investigation and observation
Privileging - Defines a physician's scope of practice and the clinical services he or she may provide
Council for Affordable Quality HealthCare (CAQH) - not-for-profit collaborative alliance of health plans
and networks which offers a standardized credentialing process
PECOS (Provider Enrollment, Chain and Ownership System) - Medicare's Internet Based provider
enrollment
NCQ (National Committee for Quality Assurance) - used to limit its accreditation to HMOs, but has
recently expanded to accredit CVOs, Behavioral Managed Health Care organizations and Physician
Organizations
JCAHO (Joint Commission on Accreditation of Healthcare Organizations - started out as a hospital
accreditation org, accredits all types of MCOs through its health care network accreditation program.
They Also have a specific set of standards for PPOs and Managed Behavioral Health Care Orgs
AAHCC (American Accreditation HealthCare Commission) - only accredits orgs that specialize in carry out
utilization reviews. They have recently broadened their focus to accredit MCOs.
MQC (Medical Quality Commission) - The smallest accreditation group, accredits medical groups and
Independent Practice Associations (IPAs)
Exclusive Managed Indemnity - In this type of plan, patient is free to go to any provider, but plan
requires some pre-certification by the payer for inpatient stays and some outpatient procedures
, PHO (Physician Hospital Organization) - Tied to a specific hospital, negotiates with the Managed Care
organization (MCO) for integrated or affiliated services with the hospital
PPO (Preferred Provider Organization) - providers are contract providers and maintained in a network
listing provided to beneficiaries. They may self refer and see any specialist as long as they stay within the
network.
Silent PPO - A plan that has two ways to access your contracted discount fee plan.
HMO (Health Maintenance Organization) - Contract that typically uses a captitated form of
reimbursement and limits the ability of a patient to see a specialist without a referral from a PCP as a
means to control costs
Group Model (HMO) - consists of private practice physicians and other providers, including hospitals,
working under contract with the HMO, accepting discount FFS or capitation Per Member Per Month
(PMPM). Usually a PCP, 'gatekeeper', and patient cannot see a specialist without referral from the
gatekeeper.
Staff Model (HMO) - providers are employees of the HMO and only provide services to hose HMO
beneficiaries
Independent Practice Association (IPA) - a separate legal entity that can either organize physicians and
contract on their behalf with MCOs to provide services, or can actually become the HMO and service the
covered lines
Medical Service Organizations (MSO) - provides physical management services to the practice and
supplies on a negotiated basis utilizing economies of scale for purchase power
Physician Administrative Organization (PAO) - has its own independent holding or management
company that acts as an agent for the physician to negotiate for the type and amount of
reimbursement, develop and oversee quality control, formulate utilization guidelines and to manage
credentialing and peer review.
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