KEY AAAHS CORE STANDARDS

Question 1

GOVERNING BODY

Answer 1

Addresses and is fully and legally responsible for the operation and performance of the organization. This can be done directly or by appropriate professional delegation.

Question 2

How often must the governing body meet?

Answer 2

must meet at least annually and keep minutes or other records as may be required for the orderly conduct of the organization.

Question 3

How must credentials be verified?

Answer 3

Credentials must be verified according to the procedures established in bylaws, rules and regulations. Provisions must be made for expeditious processing of applications for clinical privileges.

Question 4

What is the three phase process to assess and validate qualifications to provide services?

Answer 4

1. Establish minimum training, experience, and other requirements for physicians and other healthcare professionals
2. Establish a process to review, assess, and validate an individual’s qualifications, including education, training, experience, certification, licensure, and any other competence-enhancing activities against the organization’s established minimum requirements
3. Carries out review, assessment, and validation outlined in the organization’s description of the process

Question 5

What is the governing body required to do?

Answer 5

• establish and is responsible for a credentialing and reappointment process and applying criteria uniformly to all individuals who provide patient care
• approve mechanisms for credentialing, reappointment, and granting of privileges, suspending or terminating clinical privileges, including provisions for appeal of such decisions
• either directly or by delegation, make initial appointment, reappointment, and assignment or curtailment of clinical privileges based on peer evaluation (must be consistent with state law)
• have specific criteria for initial appointment and reappointment of physicians and dentists
• make provisions for expeditious processing of clinical privileges applications

Question 6

What information must be monitored on an ongoing basis?

Answer 6

date sensitive information such as licensure, professional liability insurance (if required), certifications, DEA registrations, and other such items, where applicable,

Question 7

What does it mean to monitor on an ongoing basis?

Answer 7

Appointment, Expiration, Reappointment

Question 8

True or False: An organization can grant appointment or privileges based solely upon the fact that another organization allowed privileges

Answer 8

False. The organization has its own independent process of credentialing and privileging that includes review and approval by the governing body.

Appointment or privileges may not be approved solely on the basis that another organization, such as a hospital, took such action, although this information can be used in consideration of the application.

Question 9

When creating a process for initial appointment of an allied health professional, what should be taken in to account?

Answer 9

1. state law
2. evidence of education
3. training
4. experience
5. competency

Question 10

What is a CVO?

Answer 10

Credentials Verification Organization. A credentials verification organization (CVO) is an organization that gathers data and verifies the credentials of doctors and other health care practitioners. A CVO typically provides credentialing support to health plans and other entities providing health care services to consumers.

Question 11

It is acceptable to use a CVO in facilitating privilege applications?

Answer 11

The use of a CVO is acceptable as long as there has been a proper assessment of capability and quality.

Question 12

Is primary data source verification acceptable if provided by a third party?

Answer 12

Another health care organization, such as a hospital or group practice, that has carried out primary source or acceptable secondary source verification, provided it supplies directly, without transmission or involvement by the applicant or other third party, original documents or photocopies of the verification reports it has relied upon. A statement that it has performed verification is not sufficient.

Question 13

True or False: Documents, Diplomas, certificates, or transcripts can be provided by the applicant.

Answer 13

FALSE. Documents, diplomas, certificates or transcripts provided directly by the applicant rather than by the primary or secondary source are not acceptable.

Question 14

FAIR HEARING AND APPEAL PROCESS (Standard 03.01.20)

Answer 14

The hospital shall have a fair hearing plan for members of the Medical Staff and allied health practitioners. Individuals involved in Peer Review activities shall be impartial peers and shall not have an economic interest in and/or a conflict of interest with the subject of the Peer Review activity. Impartial peer would also exclude individuals with blood relationships, employer/employee relationships, or other potential conflicts that might prevent the individual from giving an impartial assessment, or give the appearance for the potential of bias for or against the subject of the Peer Review.
The fair hearing and appeal process may differ for members of the Medical Staff and nonmembers (Allied Health Practitioners). The fair hearing plan outlines the circumstances under which a practitioner may request (or waive) this mechanism:
• Denial.
• Modification or changes in appointment/reappointment category.
• Initial or re-granting of privileges with final review/action by the Governing Body.

Question 15

Under which circumstances can a practitioner initiate a fair hearing or appeal?

Answer 15

1. Denial of Privileges
2. Modification or changes in appointment/ reappointment category.
3. Initial or re-granting of privileges with final review/ action by the Governing Body

Question 16

When would UTILIZATION OF OSTEOPATHIC METHODS & CONCEPTS COMMITTEE (OMCC) (Standard 03.05.01) be required?

Answer 16

If a hospital has ten or more Doctor’s of Osteopathic Medicine who admit and manage patients.

Question 17

What is the time frame for processing of applications per Standard 03.06.08?

Answer 17

A recommendation shall be made to the Medical Executive Committee (MEC) within 60 days of receipt of completed application. The recommendations of the Credentials Committee (function) will be based on individual practitioner’s qualifications and competency at the time the privileges are requested. All recommendations to the Medical Executive Committee (MEC) shall contain a delineation of the privileges to be extended to the applicant.

Question 18

What is OPPE?

Answer 18

Ongoing Professional Practice Evaluation.

Question 19

define Ongoing Professional Practice Evaluation

Answer 19

Ongoing professional practice evaluation (OPPE) information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), and/or to revoke an existing privilege prior to or at the time of renewal.

Question 20

Why is OPPE important?

Answer 20

To ensure the delivery of safe and competent care

Question 21

What should be addressed by the Medical Staff in assessing OPPE?

Answer 21

1. Reasons for ongoing professional practice performance evaluations
2. Identification of performance indicators specific to each department of the medical staff
3. Data collection methods
4. Individual(s) responsible for data collection
5. Sources of data, e.g., medical records
6. Frequency of data collection
7. Methods for evaluation and analysis of data
8. Confidentiality and security of data
9. Individuals that may access individual practitioner’s professional practice data
10. Explanation that data will be used as a measure of competency and will be reviewed at time of reappointment to determine eligibility
11. Evaluation of low volume practitioners
12. Triggers for additional, focused monitoring Processes are established to ensure the confidentiality and security of the ongoing professional practice

Question 22

what is FOCUSED PROFESSIONAL PRACTICE EVALUATION (Standard 03.15.02)

Answer 22

The organized medical staff defines the circumstances requiring additional, focused monitoring and evaluation of a practitioner’s professional performance. The focused professional practice evaluation (FPPE) process is designed to be a fair, balanced, and
educational approach to ensure the competency of the staff. Focused professional practice evaluation (FPPE) is consistently implemented in accordance with the criteria and requirements defined by the organized medical staff.

Question 23

Information specific to the applicant’s current licensure status, training, and current competence must be gathered by the hospital using a defined credentialing process that is based on ________ , approved by the ________ , and documented in _________.

Answer 23

medical staff recommendations
governing body
the medical staff bylaws

Question 24

How are verifications to be accomplished?

Answer 24

Verification must be in writing and must come from the primary source, if possible, or from a CVO. (Note: Joint Commission also includes some designated equivalent sources that may be used in lieu of primary source.)

Question 25

How should the practitioner’s identity be verified?

Answer 25

The provider must present in person and show a current picture hospital ID, or a valid state or Federal ID with a photo. this could include a driver’s license or passport.

Question 26

True or False: The medical staff must actually review and analyze all relevant information received regarding current licensure status, training, experience, current competence, and ability to perform the requested privileges through a clearly defined process.

Answer 26

True.

Question 27

The organization develops and consistently applies criteria that will be considered in the decision to grant, limit, or deny a requested privilege. These criteria are based on recommendations by the ______and approved by the ______.

Answer 27

medical staff

governing body

Question 28

Criteria considered in the decision to grant, limit or deny a requested privilege must be directly related to ____________.

Answer 28

quality of health care, treatment, and services or, if criteria are not related to quality of care, there must be evidence that the impact of the resulting decisions on the quality of care, treatment, and services has been evaluated.

Question 29

Who has the final authority for granting, renewing, or denying privileges?

Answer 29

The governing body or its delegated committee

Question 30

True or False: Privileges can be granted for a period not to exceed three years.

Answer 30

FALSE.

Privileges cannot exceed two years.

Question 31

The privileging decision must be communicated to the requesting practitioner within what time frame?

Answer 31

a time frame specified in the medical staff bylaws.

Question 32

True or False: In the case of denial, the applicant must not be told of the reason for denial.

Answer 32

False
In the case of a denial, the applicant must be told the reason for denial. The privileging decision must be distributed and made available to all appropriate internal and/or external persons or entities, as defined by the organization and applicable law. The practitioner must be notified of available due process or, when applicable, the option to implement the fair hearing and appeal process.

Question 33

Can the credentialing and privileging process be expedited?

Answer 33

If it chooses, the governing body can use an expedited process for initial appointments and for reappointments to the medical staff and when granting privileges. The governing body may delegate these decisions to a committee consisting of at least two voting governing body members. Expedited credentialing may not be used if the applicant’s application is incomplete or the medical staff executive committee makes a final recommendation that is adverse or has limitations. Criteria developed by the medical staff for the expedited process must be followed.

Question 34

Name three situations that should be evaluated on a case by case basis and would typically lead to ineligibility for expedited credentialing. *It should be noted that the standard does not

Answer 34

• the applicant has current or previously successful challenge to licensure or registration;
• the applicant has had an Involuntary termination of medical staff membership or involuntary limitation, reduction, denial, or loss of clinical privileges; or
• the applicant has had an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment.

Question 35

What is MS.10.01.01 – Fair Hearing and Appeals Process for Adverse Privileging Decisions

Answer 35

The medical staff must have a fair hearing and appeal process for addressing adverse decisions regarding reappointment, denial, reduction, suspension, or revocation of privileges that relate to quality of care, treatment, and service issues. A fair hearing and appeals process allows the practitioner the opportunity to defend him or herself against the adverse action before an unbiased hearing panel of the medical staff.

Question 36

Under MS.10.01.01 Fair Hearing and Appeals process, the practitioner has the opportunity to ____________ the decision of the hearing panel to the ___________.

Answer 36

appeal the decision

governing body.

Question 37

Describe the Fair Hearing process.

Answer 37

The hearing and appeals procedure must be fair and must include a mechanism to schedule a hearing, procedures for the hearing to follow, the composition of the hearing committee as a committee of impartial peers, and a governing body mechanism to appeal adverse decisions. The process may differ for medical staff members and those nonmembers who are granted privileges.

Question 38

Recommendations for staff membership/ appointment are made by___________

Answer 38

Medical Staff

Question 39

The medical staff makes recommendations to _______ for medical staff appointment

Answer 39

the governing body

Question 40

The medical staff makes recommendations to the governing body for medical staff appointment as a part of it’s oversight of __________, __________, and ______ provided by privileged practitioners.

Answer 40

Quality of Care
treatment
services

Question 41

Who develops and utilizes criteria for medical staff membership?

Answer 41

The Medical Staff

Question 42

Criteria for medical staff membership should be designed to assure the medical staff and governing body that patients will receive quality ____, ___ and ___.

Answer 42

care
treatment
services

Question 43

Appointments and subsequent reappointments cannot exceed a period of __________years.

Answer 43

Two

Question 44

Hospital sponsored educational activities must be prioritized by ___________

Answer 44

the medical staff

Question 45

Hospital sponsored education activities (CE) should relate, at least in part to:

Answer 45

the type and nature of care, treatment, and services offered by the hospital and on the findings of performance improvement activities.

Question 46

What is a LIP?

Answer 46

Licensed Independent Practitioner

Question 47

Per NCQA a well defined credentialing and recredentialing process is used for what purpose?

Answer 47

To evaluate and select licensed independent practitioners to provide care to members

Question 48

Credentialing policies and procedures specify what?

Answer 48

• Types of practitioners to credential and recredential
• Verification sources used
• Credentialing and recredentialing criteria
• Process for making credentialing and recredentialing decisions
• Process for managing credentialing files that meet the organization’s criteria
• Process for delegating credentialing or recredentialing
• Process for ensuring that credentialing and recredentialing are conducted in a nondiscriminatory manner
• Process for notifying practitioners if information obtained during the organization’s credentialing process varies substantially from information they provided to the organization
• Process for ensuring that practitioners are notified of the credentialing and recredentialing decision within 60 calendar days of the committee’s decision
• Medical director or other designated physician’s direct responsibility and participation in the credentialing program
• Process used for ensuring the confidentiality of all information obtained in the credentialing process, except as otherwise provided by law
• Process for ensuring that listings in practitioner directories and other materials for members are consistent with credentialing data, including education, training, certification and specialty.

Question 49

Who do credentialing standards apply to?

Answer 49

Credentialing standards apply to all LIPs or groups of practitioners who provide care to members and practitioners who are licensed, certified or registered by the state to practice independently.
They also apply to practitioners with an independent relationship with organization, meaning the organization employs, contracts with, or otherwise directs its members to the practitioner for care.

They also apply to practitioners with an independent relationship with organization, meaning the organization employs, contracts with, or otherwise directs its members to the practitioner for care.

Question 50

An organization’s policy must describe the sources used to _____________.

Answer 50

verify credentialing information

Question 51

Verification resources can include

Answer 51

primary source, a contracted agent of the primary source, or other NCQA-accepted sources listed for the credential.

Question 52

Per NCQA, can a practitioner provide care to members prior to be credentialed?

Answer 52

No. The organization determines which practitioners can participate within its network. It must credentials practitioners before the practitioners provide care to members.

Question 53

The criteria required to reach credentialing decisions must be defined and must be designed to __________________.

Answer 53

Assess a practitioner’s ability to deliver care

Question 54

Credentialing policies and procedures must:

Answer 54

• describe the process used to determine and approve files that meet criteria (all practitioner files can be presented to the Credentialing Committee or the organization may designate approval authority of clean files to the medical director or to an equally qualified practitioner)
• describe any credentialing activities that may be delegated, how the decision is made to delegate, and f the organization does or does not delegate credentialing activities
• specify that the organization does not base credentialing decisions on an race, ethnic/national identity, gender, age, sexual orientation or patient type (e.g., Medicaid) in which the practitioner specializes
• have a process for preventing and monitoring discriminatory practices including taking proactive steps to protect against discrimination occurring in the credentialing and recredentialing processes including at least annual monitoring for discrimination in credentialing and recredentialing practices
• describe the process for notifying practitioners when credentialing information obtained from other sources varies substantially from that provided by the practitioner
• specify that the time frame for notifying applicants of initial credentialing decisions and recredentialing denials does not exceed 60 calendar days from the Credentialing Committee’s decision (not required to notify practitioners regarding recredentialing approvals)
• describe the medical director’s or other designated physician’s overall responsibility and participation in the credentialing process
• describe the process for ensuring confidentiality of information collected during credentialing
• describe the process for making sure that information provided in member materials and practitioner directories is consistent with the information obtained during the credentialing process

Question 55

The organization must notify the practitioner about the _____________submitted to support his/her credentialing application, to __________ information, and to ______________________.

Answer 55

right to review information
correct erroneous
be informed of the status of their credentialing or recredentialing application.

Question 56

Per NCQA guidelines, there must be a Credentialing Committee which utilizes a ____________ to make recommendations regarding credentialing decisions. The Credentialing Committee’s makeup must have representation _____________________.

Answer 56

peer review process

from a range of participating practitioners.

Question 57

The committee must be given the opportunity to review the credentials of all practitioners credentialed or recredentialed who do not meet the organization’s established criteria, and to _________. The organization must consider this advice. The committee must give thoughtful consideration to the credentialing elements before making recommendations and _________________

Answer 57

offer advice

document discussions in minutes.

Question 58

Who is responsible for reviewing files?

Answer 58

The Credentialing Committee may review all files or it may give the medical director (or approved qualified physician designee) authority to evaluate and approve files.

Question 59

Policies and procedures must describe the process used to determine what applications meet the organization’s criteria and must assign the ___________ or ____________ the authority to determine that the file is “clean”.

Answer 59

medical director

designee

Question 60

What action is taken once a file is deemed by the medical director or their designee to be “clean”?

Answer 60

The Medical Director would then evaluate and approve the file. Evidence of this evaluation and approval would then be documented in the file.

Question 61

True or False: Even if a review board or governing body reviews a decision after the Credentialing Committee, NCQA considers the decision made by the Credentialing Committee to be final.

Answer 61

True

Question 62

Credentials must be verified within _________and must be _______at the time of the credentialing committee’s (or Medical Director’s) review and approval

Answer 62

the specified time limits

valid

Question 63

Under NCQA guidelines, when can provisional credentialing be used?

Answer 63

When it is in the best interest of members to have a practitioner available before the initial credentialing process is complete.

Question 64

Under NCQA guidelines, what conditions must be met in order to allow provisional credentialing?

Answer 64

• There is PSV of a current, valid license to practice
• There is written confirmation of the past five years of malpractice claims or settlements from the malpractice carrier, or NPDB query
• There is a complete application and signed attestation
• The Credentialing Committee bases the decision to provisionally credential a practitioner based on the above information
• Provisional status cannot last for more than 60 calendar days at which time the full credentialing process must be completed
• A practitioner can only be provisionally credentialed once.

Question 65

Does NCQA allow for an organization to set standards for practitioner office sites?

Answer 65

Yes.

Question 66

What standards does NCQA allow an organization to set regarding practitioner office sites?

Answer 66

1. physical appearance
2. accessibility
3. adequacy of waiting and/ or exam space
4. adequacy of medical treatment
5. adequacy of record keeping

Question 67

How would an organization implement appropriate interventions regarding quality of a practitioner’s office?

Answer 67

• Continually monitoring member complaints for all practitioner sites and performing a site visit within 60 days if a threshold was met
• Instituting actions to improve offices that do not meet thresholds
• Evaluating effectiveness of the actions at least every six months, until deficient offices meet the thresholds
• Documenting follow-up visits for offices that had subsequent deficiencies.