BASICS & DEFINITIONS

Question 1

NAMSS

Answer 1

National Association Medical Staff Services - leading organization for healthcare credentialing professionals that administers CPCS certification

Question 2

CPCS

Answer 2

Certified Provider Credentialing Specialist - certification for professionals who verify and evaluate healthcare practitioners’ qualifications in hospitals, health plans, and CVOs

Question 3

CVO

Answer 3

Credentials Verification Organization - entity that provides primary source verification services for healthcare organizations.

Two types: Organization-specific (internal) and Independent (external)

Question 4

NPDB

Answer 4

National Practitioner Data Bank - federal database containing adverse actions, malpractice payments, and disciplinary actions against healthcare practitioners

Question 5

FSMB

Answer 5

Federation of State Medical Boards - organization representing medical boards that offers reports of physician sanctions as reported by state licensing boards

Question 6

AMA Masterfile

Answer 6

American Medical Association database containing verified education, training and board certification information for physicians; considered a designated equivalent source

Question 7

Primary Source Verification (PSV)

Answer 7

Process of obtaining verification directly from the original source of a credential (e.g., directly from medical school, residency program, or licensing board)

Question 8

Designated Equivalent Source

Answer 8

Organization recognized by accrediting bodies as providing reliable verification equivalent to primary source (Example: AMA Masterfile for physician education verification)

Question 9

Credentialing

Answer 9

Process of obtaining, verifying, and assessing qualifications of a healthcare practitioner to provide patient care services in or for a healthcare organization

Question 10

Privileging

Answer 10

Process of authorizing a practitioner’s specific scope of patient care services based on evaluation of credentials and performance

Question 11

Licensed Independent Practitioner (LIP)

Answer 11

healthcare provider permitted by law to provide care without supervision (e.g., physicians, dentists)

Question 12

AHP/NPP

Answer 12

Allied Health Professional/Non-Physician Practitioner - healthcare providers such as nurse practitioners, physician assistants, and clinical psychologists

Question 13

Time-Sensitive Verification

Answer 13

Documentation obtained within specific timeframes (varies by accreditor) before credentialing decision is made

Question 14

Ongoing Monitoring

Answer 14

Continuous oversight of practitioner credentials between reappointment cycles, including license status, sanctions, and performance

Question 15

Clean File

Answer 15

Credentialing file with no red flags, adverse actions, gaps, or negative information that meets all verification requirements

Question 16

HCQIA

Answer 16

Health Care Quality Improvement Act of 1986 - Provides practioners immunity from liability for good-faith peer review activities and established NPDB reporting requirements

Question 17

CMS/Medicare CoPs

Answer 17

Medicare Conditions of Participation - Requirements hospitals must meet to participate in Medicare/Medicaid programs; found in Code of Federal Regulations

Question 18

EMTALA

Answer 18

Emergency Medical Treatment and Active Labor Act - Requires hospitals to provide emergency medical screening and stabilizing treatment regardless of ability to pay

Question 19

Medical Staff Bylaws

Answer 19

Governing document that defines medical staff organization, responsibilities, and processes for credentialing and privileging

Question 20

Rules and Regulations

Answer 20

Details what medical staff appointees can/cannot do; includes specific clinical processes, ER coverage, consultation guidelines, etc.

Question 21

Policies and Procedures

Answer 21

Documents describing specific processes and actions for managing credentialing and privileging activities

Question 22

Work History Gap

Answer 22

Any period over 30 days not accounted for in a practitioner’s professional experience that requires explanation

Question 23

Red Flags

Answer 23

Concerning information in credentials file requiring investigation (e.g., unexplained gaps, disciplinary actions, multiple malpractice claims)

Question 24

Attestation

Answer 24

Practitioner’s signed statement confirming accuracy and completeness of application information

Question 25

Verification Timeframes

Answer 25

Maximum allowed time between credential verification and decision-making (varies by accreditor - e.g., 180 days for NCQA)

Question 26

Current Competence

Answer 26

Demonstrated ability to provide quality care in present time, verified through performance data, peer references, and activity logs

Question 27

FPPE

Answer 27

Focused Professional Practice Evaluation - Process for evaluating practitioners when initially granted privileges or when concerns arise

Question 28

OPPE

Answer 28

Ongoing Professional Practice Evaluation - Continuous monitoring of practitioner performance between reappointment cycles

Question 29

Core Privileges

Answer 29

Pre-defined set of privileges granted to practitioners in a specific specialty based on standardized qualifications

Question 30

Delineation of Privileges

Answer 30

Detailed listing of specific procedures and activities a practitioner is authorized to perform

Question 31

Temporary Privileges

Answer 31

Time-limited authorization to practice while awaiting completion of full credentialing process

Question 32

Primary Source Documentation

Answer 32

Written verification received directly from original source showing date verified, source, and name of person verifying

Question 33

Peer Reference

Answer 33

Professional evaluation from colleague in same specialty who has personal knowledge of applicant’s competence

Question 34

Credentials File

Answer 34

Organized collection of verified documents supporting practitioner’s qualifications and privileges

Question 35

Peer Review

Answer 35

Evaluation of practitioner’s professional performance by others in same profession or specialty

Question 36

Quality Metrics

Answer 36

Measurable aspects of care used to evaluate practitioner performance (e.g., outcomes, complications, compliance with standards)

Question 37

Governing Body

Answer 37

Ultimate authority responsible for credentialing and privileging decisions (typically Board of Directors)

Question 38

Medical Executive Committee (MEC)

Answer 38

Committee that oversees medical staff activities and makes recommendations to governing body

Question 39

Credentials Committee

Answer 39

Group responsible for reviewing and evaluating practitioner qualifications and making recommendations

Question 40

Telemedicine

Answer 40

Provision of medical services from distant site to originating site requiring specific credentialing considerations

Question 41

Disaster Privileges

Answer 41

Emergency authorization to practice during disaster situations with modified verification requirements

Question 42

Locum Tenens

Answer 42

Temporary practitioner who substitutes for regular staff member during absence