CPCS Wizard

Question 1

According to the TJC Medical Staff Membership appointments and granting or denying initial and renewed privileges must be based off on evidence of?

Answer 1

education and training
licensure
competence
physical ability to care for patients

Question 2

Individual practitioner’s ability to perform each task, activity and privilege must be individually assessed is required by what accreditation body?

Answer 2

ACHC/HFAP

Question 3

What regulatory body requires an application without any limitations in ability to perform the functions of the position with or without accommodations?

Answer 3

CMS Managed Care Manual

Question 4

What accreditation body requires an application to include reasons for the applicant’s inability to perform essential functions of the position?

Answer 4

NCQA

Question 5

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?

Answer 5

URAC

Question 6

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?

Answer 6

AAAHC

Question 7

The TJC requires hospitals verify that practitioner requesting approval is the same practitioner identified in the credentialing application by reviewing?

Answer 7

1) current picture hospital ID card
2) valid picture ID issued by state or federal agency (driver’s license or passport)

Question 8

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

Answer 8

Medicare CoP

Question 9

Appointment Timeframe should not exceed 3 years or as required by law and regulation if shorter falls under what accrediting body’s requirements?

Answer 9

TJC

Question 10

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)

Answer 10

Det Norske Veritas

Question 11

According the ACHC/HFAP Reappraisal is conducted at a minimum?

Answer 11

every 24 months/2 years or sooner if required by State Law or other regulation.

Question 12

According to CMS Managed Care Manual how often must reappraisal/recredentialing occur?

Answer 12

At least every 3 years

Question 13

NCQA recredentialing cycle must be completed within ______ months from the last recredentialing/Credentialing date to the __________

Answer 13

36, month

Question 14

Which managed care accrediting body requires recredentialing to be completed within 3 years to the month (i.e June 2022 - June 2025)

Answer 14

URAC

Question 15

AAAHC requires reappointment be completed how often?

Answer 15

Every three years or sooner if required by State Law or organizational policies.

Question 16

TJC requires reappointment to be completed within 3 years to the ________ and __________?

Answer 16

Month and day

Question 17

What accrediting/regulatory bodies do not specifically address attestations in their requirements?

Answer 17

CMS Cop, TJC, ACHC/HFAP, DNV

Question 18

Who must assure the medical staff has bylaws and that they comply with federal and state laws and the requirements of the CoP?

Answer 18

Governing Board

Question 19

____________ requires compliance with Medicare CoPs, state and local laws?

Answer 19

ACHC/HFAP

Question 20

According to the CMS Managed Care Manual applications must be signed, dated include attestation by applicant of the

Answer 20

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.

Question 21

According to CMS Managed Care Manual Verification time limit of the attestation can be no more than __________ at the time of appointment.

Answer 21

6 months

Question 22

Verification time limit for health plan of attestation according to NCQA

Answer 22

365 days

Question 23

Verification time limit for CVO of attestation according to NCQA

Answer 23

305 days

Question 24

According to NCQA applicant must complete an application that includes an attestation which includes ________________

Answer 24

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

Question 25

According to NCQA verification time limit for attestations is ?

Answer 25

365 days for Health Plan and 305 days for CVO.

Question 26

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?

Answer 26

NCQA

Question 27

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

Answer 27

False – CMS Managed Care Manual

Question 28

Which accrediting body requires a review of experience for continuity and relevance with documentation of any interruptions

Answer 28

AAAHC

Question 29

Which accrediting body requires that the medical staff application include a request for information regarding any criminal history for the past 7-10 years

Answer 29

ACHC (formerly HFAP)

Question 30

In the hospital environment, what determines if a non-physician practitioner can apply for membership and/or privileges.?

Answer 30

Governing board approval and in compliance with state law

Question 31

When does the TJC require organizations to query the NPDB?

Answer 31

When clinical privileges are initially granted, on renewal of privileges, and when new privileges are requested (including temporary privileges

Question 32

Which accrediting body requires verification of the past five years of malpractice liability actions

Answer 32

ACHC (formerly HFAP)

Question 33

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

Answer 33

True

Question 34

Which regulatory agencies and accrediting bodies allow the organization to only verify the highest level of education or training attained?

Answer 34

1) CMS Managed Care Manual
2) NCQA
3) URAC

Question 35

Within what time frame must a hospital verify licensure when granting disaster privileges at a TJC-accredited hospital?

Answer 35

72 hours or as soon as the disaster is controlled.

Question 36

When must an applicant be placed on a Focused Professional Practice Evaluation

Answer 36

Initial granting of privileges or quality
of care concerns

Question 37

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

Answer 37

CMS

Question 38

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?

Answer 38

NCQA

Question 39

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?

Answer 39

DNV

Question 40

Which designated equivalent source is recognized for verification of residency for a
doctor of osteopathy

Answer 40

AMA Physician Masterfile and AOA
Physician Database

Question 41

Which accrediting body will accept a letter from the insurance company confirming coverage amounts for practitioners with a future start date

Answer 41

URAC

Question 42

Which accrediting body requires an equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses?

Answer 42

TJC

Question 43

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

Answer 43

TJC

Question 44

What does NCQA recognize as the highest level of post-graduate training?

Answer 44

Residency

Question 45

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?

Answer 45

1) CMS,
2) ACHC (formerly HFAP),
3) DNV

Question 46

Which accrediting body recognizes the Fraud and Abuse Control Information Systems (FACIS) as a source for verification of licensure sanctions?

Answer 46

ACHC (formerly HFAP)

Question 47

When granting telemedicine privileges at a TJC originating site, what are the three credentialing options?

Answer 47

1. The originating site can fully privilege and
   credential the practitioner.
2. The originating site can use the credentialing information from the distant site
3. The originating site can use a distant site’s
   credentialing, privileging, and decision

Question 48

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?

Answer 48

URAC

Question 49

Which accrediting bodies do not require clinical privileges?

Answer 49

NCQA and URAC

Question 50

Which accrediting bodies recognize the OIG or the NPDB for verification of Medicare/Medicaid sanctions?

Answer 50

ACHC (formerly HFAP) and NCQA

Question 51

Which regulatory agency refers to “secondary sources”?

Answer 51

CMS Managed Care Manual

Question 52

What needs to be conducted when the organization receives a complaint about compromised safety or other concerns related to the delivery of care?

Answer 52

Site visit

Question 53

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?

Answer 53

ACHC (formerly HFAP)

Question 54

True or False: Verification of malpractice claims history is obtained within 180 calendar days of the attestation date according to NCQA.

Answer 54

True

Question 55

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?

Answer 55

DNV

Question 56

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.

Answer 56

False – NCQA

Question 57

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.

Answer 57

False – CMS Managed
Care Manual, NCQA

Question 58

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

Answer 58

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

Question 59

Which accrediting body requires recredentialing every three years to the month of the initial credentialing approval?

Answer 59

URAC

Question 60

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?

Answer 60

URAC

Question 61

Which accrediting bodies recognize NPDB as a verification source for licensure sanctions and Medicare/Medicaid sanctions?

Answer 61

NCQA, URAC

Question 62

Which regulatory agency states that the
governing body must assure that the medical staff has bylaws that comply with state and federal law?

Answer 62

CMS

Question 63

Which accrediting body requires a signed and dated statement releasing the organization from liability in connection with the credentialing decision?

Answer 63

AAAHC

Question 64

Which regulatory agencies or accrediting bodies allow an organization to rely on the verification activities of a state licensing board?

Answer 64

NCQA, URAC,
CMS Managed Care Manual

Question 65

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?

Answer 65

AAAHC

Question 66

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?

Answer 66

DNV

Question 67

Which accrediting body requires the organization to obtain the collaborative practice agreement or supervisory agreement when credentialing advanced
practice professionals?

Answer 67

ACHC (formerly HFAP)

Question 68

Which accrediting bodies require NPDB query at initial, reappointment, and granting temporary privileges?

Answer 68

ACHC (formerly HFAP), DNV

Question 69

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?

Answer 69

1. To meet a patient care need
2. A complete application with no red
   flags awaiting review by the MEC and
   governing body approval

Question 70

Why does CMS require the hospital to work collaboratively with federal, state, and local emergency preparedness agencies during a disaster?

Answer 70

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

Question 71

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?

Answer 71

URAC

Question 72

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?

Answer 72

CMS Managed Care Manual

Question 73

TJC requires how many forms of identification when granting disaster privileges?

Answer 73

Two

Question 74

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?

Answer 74

NCQA

Question 75

Identify the two accepted verification sources of the DEA for a Medicare Advantage health plan.

Answer 75

1. DEA issuing agency
2. Copy of the certificate

Question 76

Which accrediting bodies require an appointment time as defined by state law, not to exceed three years?

Answer 76

DNV, AAAHC, TJC ,
ACHC (formerly HFAP)

Question 77

True or False: TJC requires an organization to obtain peer recommendations for practitioners at reappointment.

Answer 77

False – required at initial granting of
privileges, revocation or revision
of privileges, or termination

Question 78

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?

Answer 78

NCQA

Question 79

True or False: NCQA states that the education verification time limit is no more than 6 months at the time of the appointment.

Answer 79

False – CMS Managed Care

Question 80

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?

Answer 80

DNV

Question 81

Which accrediting bodies require continuing
medical education be considered in decisions about reappointment and renewal or revision of clinical privileges?

Answer 81

TJC, DNV

Question 82

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?

Answer 82

URAC

Question 83

Which regulatory agencies and accrediting bodies do not have a requirement to obtain an attestation from the applicant?

Answer 83

CMS, TJC,
ACHC (formerly HFAP), DNV

Question 84

Which accreditation bodies require compliance with applicable regulations and law?

Answer 84

TJC, ACHC (formerly HFAP),
DNV, NCQA, URAC, AAAHC

Question 85

True or False: Lack of privileges at a hospital exclude a healthcare practitioner from participating in a Medicare Advantage health plan.

Answer 85

False

Question 86

According to TJC, what are the 6 components of a peer recommendation?

Answer 86

1. Medical knowledge
2. Patient care
3. Interpersonal and communication skills
4. Professionalism
5. Practice-based learning and improvement
6. System-based practice

Question 87

Which accrediting body accepts a copy of the DEA/CDS certificate or the certificate number?

Answer 87

URAC

Question 88

Which regulatory agency requires ongoing monitoring and resolution of grievances on a regular basis between recredentialing cycles?

Answer 88

CMS Managed Care Manual

Question 89

How many peer recommendations does DNV require at initial appointment?

Answer 89

Two

Question 90

What are acceptable documents to verify identity?

Answer 90

A current picture hospital ID card or
a valid picture ID issued by a
state or federal agency
(driver’s license or passport)

Question 91

When credentialing an organizational provider (e.g., diagnostic facility), when would a site visit be required?

Answer 91

When the organizational provider is
not accredited or has not undergone a
review by CMS or a state review in
the last three years.

Question 92

What must be obtained when the state licensing board is used for verification of education, training, or board certification?

Answer 92

Documentation confirming the
licensing board conducts primary
source verification of education,
training, or board certification.

Question 93

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?

Answer 93

CMS Managed Care

Question 94

Which practitioners must be credentialed under the URAC standards?

Answer 94

All practitioners listed in the
directory who are providing covered
healthcare services to consumers

Question 95

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?

Answer 95

DNV

Question 96

True or False: ACHC (formerly HFAP) requires that two peer references must be obtained with the same professional credential as the applicant?

Answer 96

False – one is required

Question 97

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?

Answer 97

CMS, ACHC (formerly HFAP)

Question 98

Which accrediting body requires the organization to obtain primary source verification of the volunteer from their primary hospital when granting disaster privileges.

Answer 98

ACHC (formerly HFAP)

Question 99

Which accrediting body identifies a licensure verification time limit of 180 calendar days for MCOs and 120
calendar days for CVOs?

Answer 99

NCQA

Question 100

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?

Answer 100

CMS Managed Care Manual

Question 101

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?

Answer 101

AAAHC

Question 102

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?

Answer 102

ACHC (formerly HFAP)

Question 103

Name the accrediting bodies that require the applicant to attest to the correctness and completeness of the application?

Answer 103

NCQA, URAC, AAAHC

Question 104

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?

Answer 104

URAC

Question 105

Which accrediting body states that the applicant must provide information regarding criminal convictions other than minor traffic violations?

Answer 105

AAAHC

Question 106

Which accrediting body recognizes the Federation of State Medical Boards as a source for verification of Medicare/
Medicaid sanctions?

Answer 106

NCQA

Question 107

True or False: NCQA’s standards for privileging are the same as TJC.

Answer 107

False – NCQA standards address
the credentialing process, not
privileging

Question 108

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.

Answer 108

True

Question 109

What performance measures must be included in OPPE under the ACHC (formerly HFAP) standards?

Answer 109

Two administrative measures to assess
compliance with the bylaws and hospital policies and two clinical measures to assess current competence

Question 110

Which regulatory agency and accrediting body require the patient to be informed of whom to contact to file a grievance?

Answer 110

CMS, DNV

Question 111

A residency program must be accredited to be recognized by NCQA. Name the residency accreditation programs that are accepted by NCQA

Answer 111

ACGME, College of Family
Physicians of Canada, Royal
College of Physicians and
Surgeons of Canada

Question 112

True or False: TJC states that evidence of continuing education may be requested at reappointment.

Answer 112

False – ACHC (formerly HFAP)

Question 113

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.

Answer 113

NCQA

Question 114

Which accrediting body requires recredentialing within 36 months of the previous credentialing decision, counted to the month, not the day

Answer 114

NCQA

Question 115

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?

Answer 115

URAC

Question 116

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?

Answer 116

TJC

Question 117

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?

Answer 117

NCQA

Question 118

What does CMS Managed Care verify when querying the NPDB?

Answer 118

History of professional liability
claims that resulted in settlements
or judgments paid by or on behalf
of the healthcare professional

Question 119

Which accrediting body states that a minimum of five years of relevant work history must be obtained through the practitioner’s application or CV?

Answer 119

NCQA

Question 120

Which regulatory agency states that privileges are granted on an individual basis based on character, competence, judgment, experience, and training?

Answer 120

CMS

Question 121

True or False: DNV states that action will be withheld until continuing medical education is available and verified.

Answer 121

True

Question 122

Which accrediting body defines professional liability claims history as cases that are settled or have resulted in an adverse judgment against the provider?

Answer 122

URAC

Question 123

Which accrediting body requires that the privileging process involve creating non-arbitrary criteria and an evaluation process to determine an applicant’s qualifications?

Answer 123

AAAHC

Question 124

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.

Answer 124

False – URAC

Question 125

Which regulatory agencies and accrediting bodies specify disclosure of criminal or felony convictions in their standards?

Answer 125

CMS Managed Care,
ACHC (formerly HFAP),
NCQA, AAAHC, URAC

Question 126

Which regulatory agencies and accrediting bodies address criminal background checks in their standards?

Answer 126

CMS, TJC,
ACHC (formerly HFAP)
Team

Question 127

According to CoP who can, in conjunction with state law, grant medical staff privileges or membership to nonphysician practitioners.

Answer 127

Governing body

Question 128

According to Medicare CoP The non physician practitioners can include:

Answer 128

• Physician assistant
• Clinical nurse specialist
• Certified registered nurse anesthetist
• Certified nurse midwife
• Clinical social worker
• Clinical psychologist
• Anesthesiology assistant
• Registered dietitian or nutrition specialist

Question 129

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:

Answer 129

• Physical therapist
• Occupational therapist
• Speech language therapist
• Licensed pharmacist

Question 130

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:

Answer 130

• 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.

Question 131

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

Answer 131

State Laws and Bylaws

Question 132

The governing body determines, in compliance with state law, which categories of practitioners are eligible to be
appointed to the medical staff.

Answer 132

DNV

Question 133

All other non-physician healthcare professionals who provide services to the organization’s enrollees, and who are
permitted to practice independently under state law.

Answer 133

CMS Managed Care Manual

Question 134

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:

Answer 134

• 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.

Question 135

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).

Answer 135

URAC

Question 136

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.

Answer 136

Govering Body

Question 137

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.

Answer 137

CMS (Center for Medicare
& Medicaid Services)
Conditions of Participation

Question 138

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.

Answer 138

ACHC

Question 139

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.

Answer 139

CMS Managed Care Manual

Question 140

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.

Answer 140

NCQA

Question 141

Which organization requires submission of two peer recommendations as supporting
documentation for an initial application?

a. TJC
b. DNV
c. ACHC

Answer 141

b. DNV

Question 142

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

Answer 142

c. Obtain the status of the application

Question 143

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

Answer 143

b. Malpractice coverage

Question 144

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

Answer 144

b. Clinical judgment, interpersonal skills, and technical skills

Question 145

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

Answer 145

a. 305 calendar days

Question 146

According to URAC, the applicant must be notified of the Credentials Committee decision within how many calendar days?
a. 10
b. 30
c. 60

Answer 146

b. 30

Question 147

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

Answer 147

a. Manages the formal business of the meeting.

Question 148

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

Answer 148

b. CMS

Question 149

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

Answer 149

c. 6

Question 150

What is the primary source for verification of board certification per NCQA?
a. ABMS
b. AOA
c. AMA

Answer 150

a. ABMS

Question 151

Which of the following requires criminal background checks on hospital employees?

a. TJC
b. DNV
c. ACHC

Answer 151

a. TJC

Question 152

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

Answer 152

b. At least 3 times

Question 153

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

Answer 153

a. Monitored on a regular basis

Question 154

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

Answer 154

c. 180 days

Question 155

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.

Answer 155

Temporary Privileges

Question 156

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.

Answer 156

Expedited Privileges

Question 157

A medical practitioner who temporarily takes the place of another

Answer 157

Locum Tenens

Question 158

Per TJC, these are only implemented when the hospital activates its emergency operations.

Answer 158

Disaster Privileges

Question 159

For these, consider if the request for an activity is within the hospital’s capability

Answer 159

Addition of New Privilege

Question 160

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.

Answer 160

Scope of Practice

Question 161

This organization requires a process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provide
services to its members.

Answer 161

NCQA

Question 162

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”.

Answer 162

Core Privileges

Question 163

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.

Answer 163

Laundry Lists

Question 164

Use of medical information exchanged from one site to another via electronic communications.

Answer 164

Telemedicine

Question 165

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

Answer 165

HFAP

Question 166

This can serve as a good resource for those who need additional education regarding what procedures are specific to a particular specialty.

Answer 166

ACGME Residency
Requirements

Question 167

For this, consider what training/experience is required. Are there any other requirements, such as CME, board certification, training course, or peer recommendations?

Answer 167

Develop New Privileging
Criteria

Question 168

Allows physicians to perform tasks outside of their existing privileges to save a patient’s life, limb, or organ.

Answer 168

Emergency Privileges

Question 169

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.

Answer 169

AAAHC

Question 170

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.

Answer 170

URAC

Question 171

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

Answer 171

Medicare Conditions of
Participation

Question 172

CCJET

Answer 172

These factors must be considered according to CMS CoPs: character, competence, judgment, experience and training.

Question 173

This accrediting body follows NIAHO standards

Answer 173

DNV

Question 174

An organization that gathers data and verifies the credentials of doctors and other health care practitioners.

Answer 174

Credentialing Verification
Organization (CVO)

Question 175

According to URAC, the applicant must be notified of the Credentials Committee decision within how many calendar days?
a. 10
b. 30
c. 60

Answer 175

b. 30

Question 176

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

Answer 176

a. Manages the formal business of the meeting

Question 177

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

Answer 177

b. CMS

Question 178

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

Answer 178

c. 6

Question 179

What is the primary source for verification of board certification per NCQA?
a. ABMS
b. AOA
c. AMA

Answer 179

a. ABMS

Question 180

Which of the following requires criminal background checks on hospital employees?
a. TJC
b. DNV
c. ACHC

Answer 180

a. TJC

Question 181

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

Answer 181

b. At least 3 times

Question 182

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

Answer 182

a. Monitored on a regular basis

Question 183

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

Answer 183

c. 180 days

Question 184

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

Answer 184

a. Patient accessibility

Question 185

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

Answer 185

c. Medical Staff Bylaws

Question 186

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

Answer 186

a. Collaborative agreement

Question 187

According to ACHC, reapplicants must provide recommendations from which of the following regarding privileges sought?
a. Practice partner
b. Other facilities
c. Department chair

Answer 187

c. Department chair

Question 188

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

Answer 188

b. TJC

Question 189

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

Answer 189

c. 12 months

Question 190

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

Answer 190

c. CMS

Question 191

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

Answer 191

b. With each new issuance of the list

Question 192

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

Answer 192

a. Every year

Question 193

Which of the following is the formal proposal put to a group for a vote at a meeting?
a. Appeal
b. Motion
c. Rescind

Answer 193

b. Motion

Question 194

Per AAAHC, who determines the amount of medical liability insurance coverage applicants must carry?
a. Credentials Committee
b. Governing Body
c. Medical Executive Committee

Answer 194

b. Governing Body

Question 195

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

Answer 195

c. Verbal verification from current hospital

Question 196

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

Answer 196

c. All adverse events and complaints

Question 197

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

Answer 197

c. 10

Question 198

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

Answer 198

b. URAC

Question 199

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

Answer 199

b. 30

Question 200

Per DNV, what is an acceptable source to verify licensure at reappointment?

a. FSMB
b. FCVS
c. AMA

Answer 200

c. AMA

Question 201

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

Answer 201

b. Copy of the DEA certificate

Question 202

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

Answer 202

a. Annually

Question 203

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

Answer 203

b. Documentation of prescriptive coverage

Question 204

Which of the following is an acceptable source for verification of licensure, according to DNV?

a. AMA
b. FSMB
c. FACIS

Answer 204

a. AMA

Question 205

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

Answer 205

a. Governing body

Question 206

Which of the following is a record of the meeting in written form?
a. Minutes
b. Agenda
c. Reports

Answer 206

a. Minutes

Question 207

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

Answer 207

b. TJC

Question 208

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

Answer 208

a. Evidence of continuing medical education

Question 209

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

Answer 209

b. FSMB or FACIS

Question 210

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

Answer 210

b. Adherence to medical staff rules

Question 211

According to DNV, how many peer recommendations must be obtained at initial appointment?

a. 3
b. 2
c. 1

Answer 211

b. 2

Question 212

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

Answer 212

b. NPDB

Question 213

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)

Answer 213

b. Completed attestation questions

Question 214

Which of the following is considered the presiding officer’s script?

a. Minutes
b. Agenda
c. Reports

Answer 214

b. Agenda

Question 215

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

Answer 215

a. FSMB

Question 216

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

Answer 216

c. AAAHC

Question 217

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

Answer 217

a. Current DEA number at initial and reappointment

Question 218

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

Answer 218

c. Quality of care concerns