BASICS & DEFINITIONS Flashcards
NAMSS
National Association Medical Staff Services - leading organization for healthcare credentialing professionals that administers CPCS certification
CPCS
Certified Provider Credentialing Specialist - certification for professionals who verify and evaluate healthcare practitioners’ qualifications in hospitals, health plans, and CVOs
CVO
Credentials Verification Organization - entity that provides primary source verification services for healthcare organizations.
Two types: Organization-specific (internal) and Independent (external)
NPDB
National Practitioner Data Bank - federal database containing adverse actions, malpractice payments, and disciplinary actions against healthcare practitioners
FSMB
Federation of State Medical Boards - organization representing medical boards that offers reports of physician sanctions as reported by state licensing boards
AMA Masterfile
American Medical Association database containing verified education, training and board certification information for physicians; considered a designated equivalent source
Primary Source Verification (PSV)
Process of obtaining verification directly from the original source of a credential (e.g., directly from medical school, residency program, or licensing board)
Designated Equivalent Source
Organization recognized by accrediting bodies as providing reliable verification equivalent to primary source (Example: AMA Masterfile for physician education verification)
Credentialing
Process of obtaining, verifying, and assessing qualifications of a healthcare practitioner to provide patient care services in or for a healthcare organization
Privileging
Process of authorizing a practitioner’s specific scope of patient care services based on evaluation of credentials and performance
Licensed Independent Practitioner (LIP)
healthcare provider permitted by law to provide care without supervision (e.g., physicians, dentists)
AHP/NPP
Allied Health Professional/Non-Physician Practitioner - healthcare providers such as nurse practitioners, physician assistants, and clinical psychologists
Time-Sensitive Verification
Documentation obtained within specific timeframes (varies by accreditor) before credentialing decision is made
Ongoing Monitoring
Continuous oversight of practitioner credentials between reappointment cycles, including license status, sanctions, and performance
Clean File
Credentialing file with no red flags, adverse actions, gaps, or negative information that meets all verification requirements
HCQIA
Health Care Quality Improvement Act of 1986 - Provides practioners immunity from liability for good-faith peer review activities and established NPDB reporting requirements
CMS/Medicare CoPs
Medicare Conditions of Participation - Requirements hospitals must meet to participate in Medicare/Medicaid programs; found in Code of Federal Regulations
EMTALA
Emergency Medical Treatment and Active Labor Act - Requires hospitals to provide emergency medical screening and stabilizing treatment regardless of ability to pay
Medical Staff Bylaws
Governing document that defines medical staff organization, responsibilities, and processes for credentialing and privileging
Rules and Regulations
Details what medical staff appointees can/cannot do; includes specific clinical processes, ER coverage, consultation guidelines, etc.
Policies and Procedures
Documents describing specific processes and actions for managing credentialing and privileging activities
Work History Gap
Any period over 30 days not accounted for in a practitioner’s professional experience that requires explanation
Red Flags
Concerning information in credentials file requiring investigation (e.g., unexplained gaps, disciplinary actions, multiple malpractice claims)
Attestation
Practitioner’s signed statement confirming accuracy and completeness of application information
Verification Timeframes
Maximum allowed time between credential verification and decision-making (varies by accreditor - e.g., 180 days for NCQA)
Current Competence
Demonstrated ability to provide quality care in present time, verified through performance data, peer references, and activity logs
FPPE
Focused Professional Practice Evaluation - Process for evaluating practitioners when initially granted privileges or when concerns arise
OPPE
Ongoing Professional Practice Evaluation - Continuous monitoring of practitioner performance between reappointment cycles
Core Privileges
Pre-defined set of privileges granted to practitioners in a specific specialty based on standardized qualifications
Delineation of Privileges
Detailed listing of specific procedures and activities a practitioner is authorized to perform
Temporary Privileges
Time-limited authorization to practice while awaiting completion of full credentialing process
Primary Source Documentation
Written verification received directly from original source showing date verified, source, and name of person verifying
Peer Reference
Professional evaluation from colleague in same specialty who has personal knowledge of applicant’s competence
Credentials File
Organized collection of verified documents supporting practitioner’s qualifications and privileges
Peer Review
Evaluation of practitioner’s professional performance by others in same profession or specialty
Quality Metrics
Measurable aspects of care used to evaluate practitioner performance (e.g., outcomes, complications, compliance with standards)
Governing Body
Ultimate authority responsible for credentialing and privileging decisions (typically Board of Directors)
Medical Executive Committee (MEC)
Committee that oversees medical staff activities and makes recommendations to governing body
Credentials Committee
Group responsible for reviewing and evaluating practitioner qualifications and making recommendations
Telemedicine
Provision of medical services from distant site to originating site requiring specific credentialing considerations
Disaster Privileges
Emergency authorization to practice during disaster situations with modified verification requirements
Locum Tenens
Temporary practitioner who substitutes for regular staff member during absence
