CPCS Wizard Flashcards
According to the TJC Medical Staff Membership appointments and granting or denying initial and renewed privileges must be based off on evidence of?
education and training
licensure
competence
physical ability to care for patients
Individual practitioner’s ability to perform each task, activity and privilege must be individually assessed is required by what accreditation body?
ACHC/HFAP
What regulatory body requires an application without any limitations in ability to perform the functions of the position with or without accommodations?
CMS Managed Care Manual
What accreditation body requires an application to include reasons for the applicant’s inability to perform essential functions of the position?
NCQA
Applicant with disclosure of any condition that could, without reasonable accommodation, impede the applicant’s ability to provide care according to accepted standards of professional performance or pose a threat to the health and safety of members?
URAC
According to what accrediting body requires written attestation from applicant addressing at a minimum, current physical, mental health or chemical dependency problems that would interfere with their ability to provide high quality patient care and professional services?
AAAHC
The TJC requires hospitals verify that practitioner requesting approval is the same practitioner identified in the credentialing application by reviewing?
1) current picture hospital ID card
2) valid picture ID issued by state or federal agency (driver’s license or passport)
Medical Staff must periodically conduct appraisals of its members. Absent of State Law that establishes timeframes for reappraisal, a hospital’s Medical Staff must conduct an appraisal of each practitioner at least every 24 months
Medicare CoP
Appointment Timeframe should not exceed 3 years or as required by law and regulation if shorter falls under what accrediting body’s requirements?
TJC
The length of appointment or reappointment to the medical staff and granting, renewal or revision of clinical privileges is determined by state law. If require by state law not to exceed 3 years)
Det Norske Veritas
According the ACHC/HFAP Reappraisal is conducted at a minimum?
every 24 months/2 years or sooner if required by State Law or other regulation.
According to CMS Managed Care Manual how often must reappraisal/recredentialing occur?
At least every 3 years
NCQA recredentialing cycle must be completed within ______ months from the last recredentialing/Credentialing date to the __________
36, month
Which managed care accrediting body requires recredentialing to be completed within 3 years to the month (i.e June 2022 - June 2025)
URAC
AAAHC requires reappointment be completed how often?
Every three years or sooner if required by State Law or organizational policies.
TJC requires reappointment to be completed within 3 years to the ________ and __________?
Month and day
What accrediting/regulatory bodies do not specifically address attestations in their requirements?
CMS Cop, TJC, ACHC/HFAP, DNV
Who must assure the medical staff has bylaws and that they comply with federal and state laws and the requirements of the CoP?
Governing Board
____________ requires compliance with Medicare CoPs, state and local laws?
ACHC/HFAP
According to the CMS Managed Care Manual applications must be signed, dated include attestation by applicant of the
1) correctness and completeness of the application
2) accuracy of at least 5 yrs. of relevant work history
3) any limitations in their ability to perform
4) loss of license history
5) felony convictions history
6) history of loss or limitations of privileges or disciplinary activity.
According to CMS Managed Care Manual Verification time limit of the attestation can be no more than __________ at the time of appointment.
6 months
Verification time limit for health plan of attestation according to NCQA
365 days
Verification time limit for CVO of attestation according to NCQA
305 days
According to NCQA applicant must complete an application that includes an attestation which includes ________________
1) reasons for inability to perform
2) lack of present illegal drug use, loss of licensure, or felony convictions
3) loss or limitation of privileges or disciplinary actions
4) current malpractice insurance coverage
5) current signed attestation confirming the correctness and completeness of the application.
**if an application from an external agency is used it must include the above
According to NCQA verification time limit for attestations is ?
365 days for Health Plan and 305 days for CVO.
Faxed, Digital electronic, scanned, or photocopied signatures are acceptable. Signature stamps are only acceptable if applicant is physically impaired, and disability is documented in Credentialing File according to what accrediting body?
NCQA
True or False - NCQA allows malpractice coverage to be verified via the malpractice carrier, a copy of the insurance face sheet, or attestation by the healthcare professional
False – CMS Managed Care Manual
Which accrediting body requires a review of experience for continuity and relevance with documentation of any interruptions
AAAHC
Which accrediting body requires that the medical staff application include a request for information regarding any criminal history for the past 7-10 years
ACHC (formerly HFAP)
In the hospital environment, what determines if a non-physician practitioner can apply for membership and/or privileges.?
Governing board approval and in compliance with state law
When does the TJC require organizations to query the NPDB?
When clinical privileges are initially granted, on renewal of privileges, and when new privileges are requested (including temporary privileges
Which accrediting body requires verification of the past five years of malpractice liability actions
ACHC (formerly HFAP)
True or False: TJC requires all individuals who are permitted by law and the hospital to provide patient care independently in the hospital to be credentialed and privileged under the medical staff standards
True
Which regulatory agencies and accrediting bodies allow the organization to only verify the highest level of education or training attained?
1) CMS Managed Care Manual
2) NCQA
3) URAC
Within what time frame must a hospital verify licensure when granting disaster privileges at a TJC-accredited hospital?
72 hours or as soon as the disaster is controlled.
When must an applicant be placed on a Focused Professional Practice Evaluation
Initial granting of privileges or quality
of care concerns
Which regulatory agency requires the medical staff to conduct a periodic appraisal of its members at least every 24 months absent a state law that establishes a time frame
CMS
Which accrediting body requires the organization to verify the most recent five-year period available for sanctions
or limitations on licensure in each state where the practitioner provides care for its members?
NCQA
Which accrediting body requires that the bylaws provide a mechanism for automatic suspension of clinical privileges due to the termination or revocation of Medicare or
Medicaid status?
DNV
Which designated equivalent source is recognized for verification of residency for a
doctor of osteopathy
AMA Physician Masterfile and AOA
Physician Database
Which accrediting body will accept a letter from the insurance company confirming coverage amounts for practitioners with a future start date
URAC
Which accrediting body requires an equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses?
TJC
Which accrediting body requires the medical staff to evaluate any evidence of an unusual pattern or an excessive number of professional liability actions before recommending privileges
TJC
What does NCQA recognize as the highest level of post-graduate training?
Residency
Which standards state all hospital patients must be under the care of a practitioner who has been granted medical staff privileges, or under the care of
a practitioner who is directly under the supervision of a member of the medical staff?
1) CMS,
2) ACHC (formerly HFAP),
3) DNV
Which accrediting body recognizes the Fraud and Abuse Control Information Systems (FACIS) as a source for verification of licensure sanctions?
ACHC (formerly HFAP)
When granting telemedicine privileges at a TJC originating site, what are the three credentialing options?
- The originating site can fully privilege and
credential the practitioner. - The originating site can use the credentialing information from the distant site
- The originating site can use a distant site’s
credentialing, privileging, and decision
Which accrediting body requires the application to include a disclosure of any condition that can, without reasonable accommodation, impede the applicant’s
ability to provide care according to accepted standards of professional performance or pose a threat to the health
or safety of members?
URAC
Which accrediting bodies do not require clinical privileges?
NCQA and URAC
Which accrediting bodies recognize the OIG or the NPDB for verification of Medicare/Medicaid sanctions?
ACHC (formerly HFAP) and NCQA
Which regulatory agency refers to “secondary sources”?
CMS Managed Care Manual
What needs to be conducted when the organization receives a complaint about compromised safety or other concerns related to the delivery of care?
Site visit
Which accrediting body states that a criminal background investigation is conducted based on information provided by the applicant or as required by the federal and state regulations?
ACHC (formerly HFAP)
True or False: Verification of malpractice claims history is obtained within 180 calendar days of the attestation date according to NCQA.
True
Which accrediting body holds the governing body of the originating site legally responsible for telemedicine privileging decisions when the credentialing is performed by a third-party CVO?
DNV
True or False: URAC requires a mutually agreed upon written delegation agreement describing each organization’s responsibilities, activities to be delegated, and process for evaluation and outcome,
including mechanisms for corrective action or termination if obligations are not met by either party.
False – NCQA
True or False: ACHC (formerly HFAP) states that if a healthcare professional’s DEA certificate is pending, the organization may credential the practitioner provided the
organization has adopted and implemented a process under which other DEA-certified contracted practitioners write all prescriptions that require a DEA number.
False – CMS Managed
Care Manual, NCQA
True or False: According to CMS Managed Care, credentialing is required only for physicians who provide services to the organization’s enrollees, including members of physician groups
False – also required for all other types
of healthcare professionals who provide
services to the organization’s enrollees,
and who are permitted to practice
independently under state law
Which accrediting body requires recredentialing every three years to the month of the initial credentialing approval?
URAC
Which accrediting body states that the organization can delegate credentialing but must conduct a review of the organization’s policies and credential files to ensure
compliance with the standards and the capacity to perform the delegate functions?
URAC
Which accrediting bodies recognize NPDB as a verification source for licensure sanctions and Medicare/Medicaid sanctions?
NCQA, URAC
Which regulatory agency states that the
governing body must assure that the medical staff has bylaws that comply with state and federal law?
CMS
Which accrediting body requires a signed and dated statement releasing the organization from liability in connection with the credentialing decision?
AAAHC
Which regulatory agencies or accrediting bodies allow an organization to rely on the verification activities of a state licensing board?
NCQA, URAC,
CMS Managed Care Manual
Which accrediting body requires the application to include an attestation of current physical, mental health, or chemical dependence issues that interfere with the applicant’s ability to perform high-quality
patient care and professional services?
AAAHC
Which accrediting body addresses failure to maintain the minimum specified amount of professional liability insurance as required in the medical staff bylaws as a consideration for automatic suspension of clinical privileges?
DNV
Which accrediting body requires the organization to obtain the collaborative practice agreement or supervisory agreement when credentialing advanced
practice professionals?
ACHC (formerly HFAP)
Which accrediting bodies require NPDB query at initial, reappointment, and granting temporary privileges?
ACHC (formerly HFAP), DNV
Name the two circumstances in which TJC allows the CEO or their designee, upon the recommendation of the president of the medical staff or designee, to grant temporary privileges?
- To meet a patient care need
- A complete application with no red
flags awaiting review by the MEC and
governing body approval
Why does CMS require the hospital to work collaboratively with federal, state, and local emergency preparedness agencies during a disaster?
Identify likely risks to the community,
to anticipate demands and resources
needed by hospital emergency
services and to develop plans,
methods, and coordinating networks
to address those anticipated needs
Which accrediting body allows an organization to grant “provisional” participation status for a limited time
when justified by continuity or quality of care issues on approval of the senior clinical staff person?
URAC
Which regulatory agency requires licensure verification documentation to show that the license was current at the time of the credentialing decision and obtained no
more than six months old at the time of appointment?
CMS Managed Care Manual
TJC requires how many forms of identification when granting disaster privileges?
Two
Which accrediting body allows the organization to collect a copy of the federal tort letter or an attestation from the practitioner as verification of coverage?
NCQA
Identify the two accepted verification sources of the DEA for a Medicare Advantage health plan.
- DEA issuing agency
- Copy of the certificate
Which accrediting bodies require an appointment time as defined by state law, not to exceed three years?
DNV, AAAHC, TJC ,
ACHC (formerly HFAP)
True or False: TJC requires an organization to obtain peer recommendations for practitioners at reappointment.
False – required at initial granting of
privileges, revocation or revision
of privileges, or termination
Which regulatory agency states that the 36-month recredentialing cycle begins on the date of the previous credentialing decision, and is counted to the month, not to the day?
NCQA
True or False: NCQA states that the education verification time limit is no more than 6 months at the time of the appointment.
False – CMS Managed Care
Which accrediting body states that the bylaws must include a process for approving practitioners to care for patients in the event of an emergency or disaster?
DNV
Which accrediting bodies require continuing
medical education be considered in decisions about reappointment and renewal or revision of clinical privileges?
TJC, DNV
If a provider has multiple board certifications, which accrediting body requires, at a minimum, verification of
the certification under which the practitioner will be listed in the provider directory?
URAC
Which regulatory agencies and accrediting bodies do not have a requirement to obtain an attestation from the applicant?
CMS, TJC,
ACHC (formerly HFAP), DNV
Which accreditation bodies require compliance with applicable regulations and law?
TJC, ACHC (formerly HFAP),
DNV, NCQA, URAC, AAAHC
True or False: Lack of privileges at a hospital exclude a healthcare practitioner from participating in a Medicare Advantage health plan.
False
According to TJC, what are the 6 components of a peer recommendation?
- Medical knowledge
- Patient care
- Interpersonal and communication skills
- Professionalism
- Practice-based learning and improvement
- System-based practice
Which accrediting body accepts a copy of the DEA/CDS certificate or the certificate number?
URAC
Which regulatory agency requires ongoing monitoring and resolution of grievances on a regular basis between recredentialing cycles?
CMS Managed Care Manual
How many peer recommendations does DNV require at initial appointment?
Two
What are acceptable documents to verify identity?
A current picture hospital ID card or
a valid picture ID issued by a
state or federal agency
(driver’s license or passport)
When credentialing an organizational provider (e.g., diagnostic facility), when would a site visit be required?
When the organizational provider is
not accredited or has not undergone a
review by CMS or a state review in
the last three years.
What must be obtained when the state licensing board is used for verification of education, training, or board certification?
Documentation confirming the
licensing board conducts primary
source verification of education,
training, or board certification.
Which regulatory agency and accrediting body specifies a board certification verification time limit of no more than six months old at the time of appointment?
CMS Managed Care
Which practitioners must be credentialed under the URAC standards?
All practitioners listed in the
directory who are providing covered
healthcare services to consumers
Which accrediting body states that the practitioner will provide the current DEA number at initial and reappointment if the medical staff bylaws require it as an eligibility criteria?
DNV
True or False: ACHC (formerly HFAP) requires that two peer references must be obtained with the same professional credential as the applicant?
False – one is required
Which regulatory agency and accrediting body states that the medical staff may not rely solely on board certification in making a judgment on medical staff membership?
CMS, ACHC (formerly HFAP)
Which accrediting body requires the organization to obtain primary source verification of the volunteer from their primary hospital when granting disaster privileges.
ACHC (formerly HFAP)
Which accrediting body identifies a licensure verification time limit of 180 calendar days for MCOs and 120
calendar days for CVOs?
NCQA
Which regulatory agency states that the organization needs a site visit policy that includes procedures to detect deficiencies and mechanisms in place to
address deficiencies?
CMS Managed Care Manual
Which accrediting body states specifically that a CVO is allowed but the organization must perform an assessment of the capability and quality of the CVO’s work?
AAAHC
Which accrediting body requires that the verification of hospital privileges include confirmation of appointment and affiliation dates, privileges granted, and information
regarding any disciplinary actions?
ACHC (formerly HFAP)
Name the accrediting bodies that require the applicant to attest to the correctness and completeness of the application?
NCQA, URAC, AAAHC
Which accrediting body states that, if the malpractice insurance cover sheet does not include the name of the applicant, a photocopy of those covered under the plan must be submitted to the requester on a sheet that includes the insurer’s letterhead?
URAC
Which accrediting body states that the applicant must provide information regarding criminal convictions other than minor traffic violations?
AAAHC
Which accrediting body recognizes the Federation of State Medical Boards as a source for verification of Medicare/
Medicaid sanctions?
NCQA
True or False: NCQA’s standards for privileging are the same as TJC.
False – NCQA standards address
the credentialing process, not
privileging
True or False: TJC states that licensure is verified with the primary source at the time of appointment and initial granting of privileges, at reappointment, renewal, or
revision of clinical privileges, and on expiration.
True
What performance measures must be included in OPPE under the ACHC (formerly HFAP) standards?
Two administrative measures to assess
compliance with the bylaws and hospital policies and two clinical measures to assess current competence
Which regulatory agency and accrediting body require the patient to be informed of whom to contact to file a grievance?
CMS, DNV
A residency program must be accredited to be recognized by NCQA. Name the residency accreditation programs that are accepted by NCQA
ACGME, College of Family
Physicians of Canada, Royal
College of Physicians and
Surgeons of Canada
True or False: TJC states that evidence of continuing education may be requested at reappointment.
False – ACHC (formerly HFAP)
Which accrediting body requires the organization to investigate practitioner-specific complaints from members upon receipt and must evaluate the history of complaints for all practitioners at least every six months.
NCQA
Which accrediting body requires recredentialing within 36 months of the previous credentialing decision, counted to the month, not the day
NCQA
Which accrediting body requires the applicant to reattest to the information in the application being complete and correct to the practitioner’s knowledge after 180 calendar days?
URAC
Which accrediting body requires the applicant to reattest to the information in the application being complete and correct to the practitioner’s knowledge after 180 calendar days?
TJC
Which accrediting body has a time frame
requirement for the attestation and work history review of 365 calendar days for MCOs and 305 calendar days for CVOs?
NCQA
What does CMS Managed Care verify when querying the NPDB?
History of professional liability
claims that resulted in settlements
or judgments paid by or on behalf
of the healthcare professional
Which accrediting body states that a minimum of five years of relevant work history must be obtained through the practitioner’s application or CV?
NCQA
Which regulatory agency states that privileges are granted on an individual basis based on character, competence, judgment, experience, and training?
CMS
True or False: DNV states that action will be withheld until continuing medical education is available and verified.
True
Which accrediting body defines professional liability claims history as cases that are settled or have resulted in an adverse judgment against the provider?
URAC
Which accrediting body requires that the privileging process involve creating non-arbitrary criteria and an evaluation process to determine an applicant’s qualifications?
AAAHC
True or False: AAAHC states that the credentialing program must include a statement that credentialing decisions will be based on multiple criteria related to professional competency, quality of care, and and the appropriateness of how health
services are provided.
False – URAC
Which regulatory agencies and accrediting bodies specify disclosure of criminal or felony convictions in their standards?
CMS Managed Care,
ACHC (formerly HFAP),
NCQA, AAAHC, URAC
Which regulatory agencies and accrediting bodies address criminal background checks in their standards?
CMS, TJC,
ACHC (formerly HFAP)
Team
According to CoP who can, in conjunction with state law, grant medical staff privileges or membership to nonphysician practitioners.
Governing body
According to Medicare CoP The non physician practitioners can include:
- Physician assistant
- Clinical nurse specialist
- Certified registered nurse anesthetist
- Certified nurse midwife
- Clinical social worker
- Clinical psychologist
- Anesthesiology assistant
- Registered dietitian or nutrition specialist
According to Medicare CoP - Other healthcare professionals that have a limited scope of practice, depending on state law, may be granted medical staff privileges if approved by the governing body, including:
- Physical therapist
- Occupational therapist
- Speech language therapist
- Licensed pharmacist
According to the TJC - The hospital’s governing body approves an equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses, which includes:
- a documented evaluation of the applicant’s credentials;
- an evaluation of the applicant’s current competence;
- documented peer recommendations; and
- input from individuals and committees, including the medical staff, to make informed decisions regarding
requests for privileges.
ACHC/HFAP
Standards use the term “non-physician practitioner.”
The following non-physician practitioners are eligible to apply for membership and/or clinical privileges providing they are in compliance with ________________ and the _____________:
* Physician assistant
* Nurse practitioner
* Clinical nurse specialist
* Certified registered nurse anesthetist
* Certified nurse-midwife
* Clinical social worker
* Clinical psychologist
* Anesthesiologist’s assistant
* Registered dietitian or nutrition professional
State Laws and Bylaws
The governing body determines, in compliance with state law, which categories of practitioners are eligible to be
appointed to the medical staff.
DNV
All other non-physician healthcare professionals who provide services to the organization’s enrollees, and who are
permitted to practice independently under state law.
CMS Managed Care Manual
According to NCQA Types of eligible non-physician medical practitioners include:
- nurse practitioners;
- doctoral or master’s level psychologists;
- master’s level clinical social workers;
- master’s level clinical nurse specialists or psychiatric nurse practitioners; and
- other medical or behavioral healthcare specialists who may be within the scope of credentialing.
They must be:
- are licensed, certified or registered by the state to practice independently, without direct supervision.
- have an independent relationship with the organization (e.g., organization directs members to a specific practitioner or group); and
- provide care to members under the organizations medical or nonmedical benefits.
Which accrediting body indicates that all participating providers who provide covered healthcare services to consumers and who appear in the organization’s provider directory.
These may include:
* non-physicians (e.g., nurse practitioners, physician assistants, nutritionists);
- alternative medicine providers (e.g., massage therapists, acupuncturists);
- mental health providers (e.g., psychologists, certified addiction specialists).
URAC
According to AAAHC the ______________________ provides a process, consistent with state law, for initial appointment, reappointment, and assignment or curtailment of privileges and practice for allied health care professionals.
Govering Body
According to what accrediting body ensures that the governing board must ensure that medical staff membership or privileges are not dependent solely upon certification, fellowship, or membership in a specialty society or body.
CMS (Center for Medicare
& Medicaid Services)
Conditions of Participation
According to what accreditation body must the medical staff bylaws may consider board certification at initial and reappointment when credentialing an MD
or DO; however, the recommendation cannot be based solely on the presence or absence of board certification.
Primary source verification of board certification may be obtained from ABMS specialty boards or AOA Profiles.
ACHC
According to what regulatory agency is the primary source verification required if the applicant attests to being board certified on their application.
Verification is obtained from the primary source or secondary sources identified by nationally recognized accrediting organizations as long as the secondary sources verify the information from the originating source.
Verification must be obtained for each clinical specialty area listed on the application.
Verification of board certification will satisfy the requirement for verification of education and training as long as
the education and training was primary source verified by the board.
Verification time limit: no more than six months old at the time of appointment.
CMS Managed Care Manual
According to ____________
Board certification must be verified at initial and recredentialing if an applicant claims to be board certified.
Board certification is considered the highest level of training; therefore, medical school and residency do not need to be verified.
Verification of board certification does not apply to nurse practitioners or other healthcare professionals unless
the organization lists them as board certified in the member directory.
Verification sources for all practitioner types are the
* primary source (appropriate ABMS or its member boards); or
* state licensing agency with required annual documentation that the licensing agency performs primary source
verification of board certification.
The other approved sources for physicians (MD, DO) are
* official ABMS display agents;
* the AMA Physician Masterfile;
* the AOA Profile report or AOA Physician Masterfile; and
* other U.S. boards that are not members of the ABMS or AOA, but are recognized by the organizational policies and procedures with required annual documentation that the board performs primary source verification of education and residency.
The approved source for other healthcare professionals is a registry that performs primary source verification of
board certification status with required annual documentation that the registry does so.
Verification time limit is 180 calendar days for a health plan and 120 calendar days for a CVO.
NCQA
Which organization requires submission of two peer recommendations as supporting
documentation for an initial application?
a. TJC
b. DNV
c. ACHC
b. DNV
According to NCQA, the practitioner must be notified of which of the following rights?
a. Review all verifications
b. Notification of modifications
c. Obtain the status of the application
c. Obtain the status of the application
Which of the following must be collected at reappointment, if required by the Governing Board, according to AAAHC?
a. OPPE reports
b. Malpractice coverage
c. Continuing education
b. Malpractice coverage
Which elements are included in peer recommendations per The Joint Commission?
a. Medical and clinical knowledge, professionalism, and organizational skills
b. Clinical judgment, interpersonal skills, and technical skills
c. Communication skills, organizational skills, and medical knowledge
b. Clinical judgment, interpersonal skills, and technical skills
Validation of the minimum five-year work history expires within which of the following time frames when an application is being processed by an NCQA-accredited CVO?
a. 305 calendar days
b. 365 calendar days
c. 180 calendar days
a. 305 calendar days
According to URAC, the applicant must be notified of the Credentials Committee decision within how many calendar days?
a. 10
b. 30
c. 60
b. 30
What is the role of the committee chair when conducting a meeting?
a. Manages the formal business of the meeting.
b. Challenges rulings made by the assembly
c. Determines the quorum required for each vote
a. Manages the formal business of the meeting.
Which of the following allows a practitioner to attest on a Medicare Advantage network
application evidence of malpractice coverage for managed care credentialing?
a. AAAHC
b. CMS
c. NCQA
b. CMS
When recredentialing for a Medicare Advantage health plan, the organization must ensure the attestation is obtained within how many months of the approval date?
a. 12
b. 9
c. 6
c. 6
What is the primary source for verification of board certification per NCQA?
a. ABMS
b. AOA
c. AMA
a. ABMS
Which of the following requires criminal background checks on hospital employees?
a. TJC
b. DNV
c. ACHC
a. TJC
According to ACHC, how frequently must OPPE data be collected and reviewed during the three-year reappraisal cycle?
a. At least 2 times
b. At least 3 times
c. At least 4 times
b. At least 3 times
What is the time frame required for monitoring licensure sanctions between credentialing cycles for a Medicare Advantage health plan?
a. Monitored on a regular basis
b. Routinely monitored on an ongoing basis
c. Within 30 calendar days of being published
a. Monitored on a regular basis
According to URAC, the applicant must re-attest to the correctness and completeness of the application if the signature date is greater than how many days prior to the Credentials Committee review?
a. 365 days
b. 305 days
c. 180 days
c. 180 days
This is used to fulfill an important patient care, treatment, and service need or when an initial applicant with a complete clean application awaits review and approval of the medical executive committee and the governing body.
Temporary Privileges
Per TJC, the governing body may delegate the authority to render those decisions to a committee of at least two voting members of the governing
body.
Expedited Privileges
A medical practitioner who temporarily takes the place of another
Locum Tenens
Per TJC, these are only implemented when the hospital activates its emergency operations.
Disaster Privileges
For these, consider if the request for an activity is within the hospital’s capability
Addition of New Privilege
Terminology used by national and state/provincial licensing boards for various professions that defines the procedures, actions, and processes that are permitted for the licensed individual.
Scope of Practice
This organization requires a process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provide
services to its members.
NCQA
An example of this would be “admit, evaluate, diagnose, treat, and provide consultation to patients 15 years of age and older with common and complex illnesses”.
Core Privileges
This is sometimes referred to as privilege lists or privilege cards, are detailed
checklists that itemize the procedures/conditions that applicants can
specifically request to perform/treat.
Laundry Lists
Use of medical information exchanged from one site to another via electronic communications.
Telemedicine
This organization stipulates that bylaws provide for the granting of temporary privileges during review and consideration of application, for care of specific patient(s). for locum tenens, and for times of
emergency/disaster
HFAP
This can serve as a good resource for those who need additional education regarding what procedures are specific to a particular specialty.
ACGME Residency
Requirements
For this, consider what training/experience is required. Are there any other requirements, such as CME, board certification, training course, or peer recommendations?
Develop New Privileging
Criteria
Allows physicians to perform tasks outside of their existing privileges to save a patient’s life, limb, or organ.
Emergency Privileges
The organization requires and reviews pertinent information concerning the applicant’s current physical, mental health, or chemical dependency problems that would interfere with the ability to provide high-quality patient care or services.
AAAHC
This organization requires an application that includes disclosure of any physical, mental, or substance abuse problems that could, without reasonable accommodation, impede the practitioner’s ability to provide care according to accepted standards of professional performance or pose a threat to the health or safety of patients.
URAC
In accordance with State law, including scope-of practice laws, the medical staff may also include other categories of non-physician practitioners (APPs) determined as eligible for appointment by the governing body
Medicare Conditions of
Participation
CCJET
These factors must be considered according to CMS CoPs: character, competence, judgment, experience and training.
This accrediting body follows NIAHO standards
DNV
An organization that gathers data and verifies the credentials of doctors and other health care practitioners.
Credentialing Verification
Organization (CVO)
According to URAC, the applicant must be notified of the Credentials Committee decision within how many calendar days?
a. 10
b. 30
c. 60
b. 30
What is the role of the committee chair when conducting a meeting?
a. Manages the formal business of the meeting
b. Challenges rulings made by the assembly
c. Determines the quorum required for each vote
a. Manages the formal business of the meeting
Which of the following allows a practitioner to attest on a Medicare Advantage network
application evidence of malpractice coverage for managed care credentialing?
a. AAAHC
b. CMS
c. NCQA
b. CMS
When recredentialing for a Medicare Advantage health plan, the organization must ensure the attestation is obtained within how many months of the approval date?
a. 12
b. 9
c. 6
c. 6
What is the primary source for verification of board certification per NCQA?
a. ABMS
b. AOA
c. AMA
a. ABMS
Which of the following requires criminal background checks on hospital employees?
a. TJC
b. DNV
c. ACHC
a. TJC
According to ACHC, how frequently must OPPE data be collected and reviewed during the three-year reappraisal cycle?
a. At least 2 times
b. At least 3 times
c. At least 4 times
b. At least 3 times
What is the time frame required for monitoring licensure sanctions between credentialing cycles for a Medicare Advantage health plan?
a. Monitored on a regular basis
b. Routinely monitored on an ongoing basis
c. Within 30 calendar days of being published
a. Monitored on a regular basis
According to URAC, the applicant must re-attest to the correctness and completeness of the application if the signature date is greater than how many days prior to the Credentials Committee review?
a. 365 days
b. 305 days
c. 180 days
c. 180 days
Medicare Advantage organizations must have a policy in place to conduct site visits to detect deficiencies in which of the following?
a. Patient accessibility
b. Adequacy of staff
c. Electronic medical record access
a. Patient accessibility
According to ACHC, which of the following documents should address the definition of a quorum for various meetings?
a. Rules and Regulations
b. Credentialing Policies
c. Medical Staff Bylaws
c. Medical Staff Bylaws
Which document must a nurse practitioner seeking privileges at an ACHC-accredited hospital provide with the application?
a. Collaborative agreement
b. Supervisory agreement
c. Ten-year claims history
a. Collaborative agreement
According to ACHC, reapplicants must provide recommendations from which of the following regarding privileges sought?
a. Practice partner
b. Other facilities
c. Department chair
c. Department chair
Which accrediting body uses photo ID to verify that the practitioner submitting the application is the same person whose name appears in credentialing documents?
a. ACHC
b. TJC
c. DNV
b. TJC
Per NCQA, which of the following work history gaps requires a written explanation from the applicant?
a. 3 months
b. 6 months
c. 12 months
c. 12 months
Which of the following requires a hospital to inform the patient whom they can contact to file a grievance?
a. TJC
b. ACHC
c. CMS
c. CMS
When conducting ongoing monitoring of Medicare/Medicaid sanctions for a Medicare Advantage plan, how frequently must the OIG list of excluded providers and entities be queried?
a. On a quarterly basis
b. With each new issuance of the list
c. On a semiannual basis
b. With each new issuance of the list
How frequently must the organization conduct a delegated credentialing oversight audit of the delegate’s credential files and policies, according to NCQA?
a. Every year
b. Every two years
c. Every three years
a. Every year
Which of the following is the formal proposal put to a group for a vote at a meeting?
a. Appeal
b. Motion
c. Rescind
b. Motion
Per AAAHC, who determines the amount of medical liability insurance coverage applicants must carry?
a. Credentials Committee
b. Governing Body
c. Medical Executive Committee
b. Governing Body
According to ACHC, which of the following is an acceptable source to verify identity during a disaster?
a. Confirmation from a credentialed LIP
b. Current license to practice
c. Verbal verification from current hospital
c. Verbal verification from current hospital
According to CMS, when telemedicine privileges are processed by the distant site, what information must the originating site share with the distant site at the time of reappraisal of privileges?
a. All CME and peer recommendations
b. All case logs and complaints
c. All adverse events and complaints
c. All adverse events and complaints
According to TJC, a CVO needs to be assessed against how many principles initially and periodically when performing credentialing for a hospital?
a. 15
b. 12
c. 10
c. 10
Which of the following requires the practitioner to sign and date a release to collect and verify the information in the application?
a. TJC
b. URAC
c. ACHC
b. URAC
According to the NPDB, the organization is required to report professional review action that adversely affects the privileges of a physician if greater than how many days?
a. 15
b. 30
c. 45
b. 30
Per DNV, what is an acceptable source to verify licensure at reappointment?
a. FSMB
b. FCVS
c. AMA
c. AMA
Per URAC, what is included in a recredentialing file going to the Credentials Committee?
a. Attestation of professional liability coverage
b. Copy of the DEA certificate
c. Non-expiring board certification
b. Copy of the DEA certificate
According to NCQA, how frequently must the organization conduct an audit of practitioner complaints for evidence of alleged discrimination?
a. Annually
b. Quarterly
c. Monthly
a. Annually
According to NCQA, when an organization allows for approval pending DEA, what must the practitioner submit with the application?
a. Explanation from the practitioner
b. Documentation of prescriptive coverage
c. Copy of the DEA application
b. Documentation of prescriptive coverage
Which of the following is an acceptable source for verification of licensure, according to DNV?
a. AMA
b. FSMB
c. FACIS
a. AMA
According to AAAHC, granting of privileges requires review and approval by which of the following?
a. Governing body
b. Medical Executive Committee
c. Department chair
a. Governing body
Which of the following is a record of the meeting in written form?
a. Minutes
b. Agenda
c. Reports
a. Minutes
Which of the following requires an applicant to submit a statement indicating they have no health problems that could affect their ability to perform requested privileges?
a. CMS
b. TJC
c. DNV
b. TJC
According to TJC, which of the following must be submitted by the applicant at the time of recredentialing?
a. Evidence of continuing medical education
b. OPPE report from primary admitting facility
c. Current malpractice cover facesheet
a. Evidence of continuing medical education
According to ACHC, which of the following sources are acceptable to verify license sanctions?
a. FCVS or FSMB
b. FSMB or FACIS
c. FCVS or FACIS
b. FSMB or FACIS
Per ACHC, which of the following is evaluated during the reappraisal of clinical privileges?
a. At least one peer recommendation
b. Adherence to medical staff rules
c. Current DEA registration
b. Adherence to medical staff rules
According to DNV, how many peer recommendations must be obtained at initial appointment?
a. 3
b. 2
c. 1
b. 2
According to URAC, which of the following is an accepted source to verify Medicare/Medicaid sanctions between credentialing cycles?
a. AMA
b. NPDB
c. AOA
b. NPDB
Per AAAHC, what element must a complete reappointment application include?
a. Current work history
b. Completed attestation questions
c. Name(s) for peer recommendation(s)
b. Completed attestation questions
Which of the following is considered the presiding officer’s script?
a. Minutes
b. Agenda
c. Reports
b. Agenda
Per NCQA, what entity is the primary source to query for verification of residency completion from a closed residency program?
a. FSMB
b. FCVS
c. ECFMG
a. FSMB
Which of the following accrediting bodies requires proof of medical liability coverage, if required by the organization, upon expiration?
a. NCQA
b. TJC
c. AAAHC
c. AAAHC
According to DNV, what must be obtained if the Medical Staff Bylaws require a practitioner to hold a federal narcotics registration?
a. Current DEA number at initial and reappointment
b. Verification of the DEA at initial and reappointment
c. Verification of the DEA at appointment and upon expiration
a. Current DEA number at initial and reappointment
According to TJC, when is an existing practitioner placed on a focused professional practice evaluation?
a. Granting of existing privileges
b. Granting of disaster privileges
c. Quality of care concerns
c. Quality of care concerns
