CPCS/CPMSM Exam
Applicant completes an application that includes, reasons for inability to perform, las
of present illegal drug use, loss of license or felony convictions. Loss or limitation of
privileges or disciplinary actions. Current malpractice insurance coverage, current
signed attestation confirming the correctness and completeness of the application. If
an application from an external entity is used it must include the questions and
attestations as identified above. Signature stamps are not acceptable unless the
practitioner is physically impaired and the disability is documented in the
practitioners file. - Answer- NCQA Health Plan/CVO
Which type of agenda is used on a meeting agenda to group together non-
controversial business and reports that can be approved under one motion instead of
individually approving each item? - Answer- Consent Agenda
According to NCQA under what circumstance would a Locum Tenens practitioner be
exempt from credentialing? - Answer- Covering Practitioner
According to URAC, when developing a quality auditing process, prudent practice
would be to audit what percentage of completed credentialing files? - Answer-
According to URAC, a complete credentials file should be reviewed by which
professionals? - Answer-
According to NCQA, what must be included in the organization's right to appeal
policies? - Answer- written notification when a professional review action has been
brought against a practitioner
reasons for the action
summary of the appeal rights and process
ability to request a hearing and the specific time period for submitting the request
allowing for at least 30 calendar days after the notification for practitioners to request
a hearing
allowing representation by an attorney or another person
appointment of a hearing officer or a panel of individuals to review the appeal
and written notification of the appeal decision that contains specific reasons for the
decision.
Which Accrediting body requires an attestation to the practitioners identity? -
Answer- The Joint Commission
According to HFAP, how often must a reappraisal of membership and privileges
occur? - Answer- Every 24 months
Which Accrediting Agency requires all practitioners with clinical privileges to
participate in continuing education? - Answer- DNV
,According to CMS, what criteria are used by the governing board for the selection of
medical staff members? - Answer- Character, competence, training, experience, and
judgment
Which agency requires peer recommendations be obtained at initial credentialing
and reappointment? - Answer- AAAHC
Which regulatory agency standards must be followed for a hospital to bill for
Medicare/Medicaid services? - Answer- CMS Conditions of Participation
Which Federal legislation created the National Practitioner Data Bank? - Answer-
HCQIA
According to TJC, what is required to make a recommendation to the Governing
Board? - Answer- Medical Executive Committee
According to NCQA, the application process is located in what document? - Answer-
Why it is important to check that the practitioner is not currently excluded,
suspended, debarred, or ineligible to
participate in Federal health care programs? - Answer- The facility won't get paid for
treating patients unless service is provided by authorized provider.
Which credential must be tracked on an ongoing basis? - Answer- Licensure
According to NCQA standards, an organization that discovers sanction information,
complaints, or adverse
events regarding a practitioner must take what action? - Answer- Determine if there
is evidence of poor quality that could affect the health and safety of its members.
What is the name of the entity that was established through the Health Care Quality
Improvement Act of 1986
to restrict the ability of incompetent physicians, dentists, and other health care
practitioners to move from state
to state without disclosure or discovery of previous medical malpractice payment and
adverse action history? - Answer- NPDB
When developing clinical privileging criteria, what is important to evaluate? - Answer-
Established standards of practice such as, specialty board recommendations.
What is the main reason for periodically assessing appropriateness of clinical
privileges for each specialty? - Answer- To protect patient safety by ensuring current
competency, relevance to the facility, and accepted standards
of care.
What type of specialists is most likely to perform a PTCA? - Answer- Interventional
Cardiologist
,The Joint Commission hospital standards require that clinical privileges are hospital-
specific and - Answer- Based on the individual's demonstrated current competence
and the procedures the hospital can support.
What type of procedure would be routinely performed by a cardiologist? - Answer-
Transesophageal Echocardiography
Which NCQA-required committee makes recommendations regarding credentialing
decisions? - Answer- Credentialing Committee
HFAP standards require three medical staff committees to be delineated in the
medical staff structure. Two of
them are the Medical Executive Committee and the Utilization of Osteopathic
Methods & Concepts Committee
(required for hospitals with ten or more DOs who admit patients and provide direct
patient care). What is the
other required medical staff committee? - Answer- Utilization Review Committee
If you needed to find out about what the Federal Government requires in regards to
anti-trust issues, what law
would you consult? - Answer- Sherman Anti-trust Act
Peer references should be obtained from - Answer- Practitioners in the same
professional discipline as the applicant
Patrick v. Burgett is an important case because it: - Answer- Illustrates the potential
for antitrust liability arising out of peer review activities
If a medical staff member has privileges and/or medical staff appointment revoked,
he/she must be: - Answer- Provided due process
Access to credentials files should be: - Answer- Described fully in an access policy
What body approves clinical privileges? - Answer- Governing Body or Board
What primary source verification is required by NCQA prior to provisional
credentialing? - Answer- Licensure and 5 year malpractice history or NPDB
According to The Joint Commission standards, initial appointments to the medical
staff are made for a period of: - Answer- Not to exceed two years
According to The Joint Commission standards, temporary privileges may be granted
by: - Answer- The CEO on the recommendation of the medical staff president or
authorized designee
According to The Joint Commission Standards, what must be verified with a primary
source? - Answer- Licensure, training, experience, and competence
According to NCQA standards, a copy of what is an acceptable verification of the
document? - Answer- DEA certificate
, According to NCQA standards, what organization is an acceptable source for
primary source verification of Medicare and
Medicaid sanction activity against physicians? - Answer- Federation of State Medical
Boards
According to The Joint Commission standards, which organization is considered a
designated equivalent source
for verification of board certification? - Answer- The American Board of Medical
Specialties
What organization has been recognized by The Joint Commission and NCQA to
provide primary source verification of medical school graduation and residency
training for U.S. graduates? - Answer- American Medical Association Masterfile
According to N CQA standards, the application attestation statement must affirm that
the application - Answer- Is correct and complete
According to The Joint Commission standards, medical staff bylaws should define -
Answer- The structure of the medical staff
According to The Joint Commission hospital standards, professional criteria for the
granting of clinical privileges
must include at least - Answer- Relevant training or experience, ability to perform
privileges requested, current licensure, and competence
The Joint Commission hospital standards require medical staff bylaws to include -
Answer- A mechanism for selection and removal of officers
According to NCQA standards, name an approved source for verification of board
certification? - Answer- State licensing agency if state agency conducts primary
verification of board status
According to The Joint Commission hospital standards, which of the following is a
required component of the
reappointment process? - Answer- Documentation of the applicant's health status
According to URAC's health network standards, each applicant within the scope of
the credentialing program
submits an application that includes at least what: - Answer- State licensure
information, including current license(s) and history of licensure in all jurisdictions
According to AAAHC, what must be monitored on an ongoing basis? - Answer-
Current licensure
According to The Joint Commission, a nurse practitioner functioning independently
and providing a medical
level of care must: - Answer- Be granted delineated clinical privileges
