Misc Questions Flashcards
According to AAAHC, a CVO is allowed. Accreditation or certification of the CVO by a nationally recognized organization can meet this requirement. Which of the following is a nationally recognized organization?
a. DNV
b. TJC
c. NCQA
NCQA
All these situations would lead to ineligibility for expedited credentialing except.
a. Current or previously successful challenge to licensure or registration
b. Involuntary termination of Medical Staff Membership
c. Complete application with no unexplained gaps
Complete application with no unexplained gaps
Fast-track credentialing can be used for applications that pose no problems, including new graduates or physicians fully credentialed at a sister hospital with ______?
a. DNV
b. ACHC
c. AAAHC
ACHC
When the medical staff processes a file for expedited or fast-tracking approvals, bylaws should define this process including a definition of ______________________.
a. A complete application
b. Competency
c. Primary and Secondary Sources
A complete application
What accrediting agency states organizations must ensure that provisional credentialing does not extend for more than 60 calendar days?
a. TJC
b. URAC
c. NCQA
NCQA
To meet NCQA standards, provisional credentialing files must contain what information within the specified time frames?
a. Complete application with all required attachments; no unexplained gaps; all primary source verifications received; no discrepancies identified; and documentation of current competency and ability to perform privileges.
b. PSV of current, valid license to practice; PSV of five years of malpractice history; Complete application and signed attestation.
c. Current or previously successful challenge to licensure or registration; Involuntary termination of medical staff membership; Involuntary limitation, reduction, denial, or loss of clinical privileges; Unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment
PSV of current, valid license to practice; PSV of five years of malpractice history; Complete application and signed attestation
_______ conducts a one time provisional credentialing
a. ACHC
b. NCQA
c. AAAHC
NCQA
According to Medicare COPs, surgical privileges should be reviewed and updated at least every ___.
a. 2 years
b. 3 years
c. 180 days
2 years
Criteria for expedited appointments or “fast tracking” appointments for applications should be defined by the ___________________.
a. Medical Executive Committee
b. Governing Body
c. Medical / Dental Staff Bylaws
Medical / Dental Staff Bylaws
There are various methods for delineating clinical privileges. One example is/a __________ _______, this is an exhaustive list of individual procedures or conditions.
a. Laundry List
b. Core Privileges
c. Category or Levels
Laundry List
________ is a time-limited period during which the organization evaluates and determines the practitioner’s professional performance?
a. Probation
b. OPPE
c. FPPE
FPPE
To meet NCQA standards, provisional credentialing files must contain three pieces of information within the specified time frames. What are they?
a. PSV of five years of malpractice history; Complete application & signed attestation; The recommendation of a Senior Clinical Staff Person
b. PSV of five years of malpractice history; Complete application & signed attestation; PSV of current valid license to practice
c. PSV of five years of malpractice history; Complete application & signed attestation; Verification of training
PSV of five years of malpractice history; Complete application & signed attestation; PSV of current valid license to practice
Who requires that the governing body must ensure the criteria for selection are individual character, competence, training, experience, and judgement?
a. TJC
b. URAC
c. CoPS
CoPS
Medicare CoPS regarding privileges state that the governing body must ensure the criteria for selection are individual what?
a. current licensure, relevant training or experience, current competence, and ability to perform privileges
b. PSV for current licensure or certification; PSV of relevant training; Evidence of physical ability to perform the requested privilege; Data from professional practice review from other organizations where the applicant currently has privileges (if available);Recommendations from peers/faculty; and On renewal, review of the practitioner’s performance within the hospital
c. character, competence, training, experience, and judgment
character, competence, training, experience, and judgment
Which standards require that Medical Staff Bylaws must describe the qualifications to be met by a candidate in order for the medical staff to be able to recommend appointment by the governing body?
a. NCQA abd URAC
b. DNV and TJC
c. AAAHC and Medicare CoPS
AAAHC and Medicare CoPS
The application will be processed as follows: If the file is clean (per policy) with no problems, it will be forwarded to the ______________ or his designee for approval.
a. Credentialing Committee
b. Medical Director
c. Credentialing Coordinator
Medical Director
Which accreditation specifically states that “while hospitals may use third-party CVOs to compile and verify the credentials of practitioners applying for privileges, the hospital’s governing body is still legally responsible for all privileging decisions.”
a. DNV
b. NCQA
c. AAAHC
DNV
Documentation of attendance can be done by obtaining copies of program certificates
a. ACHC
b. TJC
c. NCQA
TJC
Every 2 years evidence of continuing medical education needs to be presented by this standard.
a. ACHC / HFAP
b. TJC
c. DNV
ACHC/ HFAP
MS.15 Interpretative guidelines read that while hospitals may use third-party credentialing verification organizations to compile and verify the credentials of practitioners applying for privileges, the hospital’s governing body is still legally responsible for all privileging decisions
a. TJC
b. URAC
c. DNV
DNV
___________ states that evidence of continuing educational activities every two years may be requested?
a. TJC
b. ACHC
c. DNV
ACHC
For all facilities, evidence of __________________________ requested is required of all applicants for renewal of privileges
a. Verified CME within the past 24 months matching the
b. Board Certification is the specialty area
c. Current ability to perform privileges
Current ability to perform privileges
What accrediting body does not address CMEs for medical staff members?
a. AAAHC
b. DNV
c. ACHC
AAAHC
Which accreditation takes action until CME information is available and verified?
a. TJC
b. ACHC
c. DNV
DNV
Action Taken: clinical privileges withheld
__________ defines privileging as the process whereby the specific scope and content of patient care services (that is, clinical privileges) are authorized for a healthcare practitioner by a healthcare organization, based on evaluation of the individual’s credentials and performance
a. TJC
b. ACHC
c. URAC
TJC
The organization’s credentialing process describes the building security that adequately limits physical access to credentials information.
a. NCQA
b. URAC
c. ACHC
NCQA
What is CAMH and what aspect references the CAMH with CVOs and Delegation?
a. Center for Addiction and Mental Health (DNV)
b. Comprehensive Accreditation Manual for Hospitals (TJC)
c. Commission Accreditation Manual for Hospitals (ACHC)
Comprehensive Accreditation Manual for Hospitals (TJC)
___________ requires organization to perform an assessment of the capability and quality of the CVO’s work?
a. TJC
b. AAAHC
c. NCQA
AAAHC
This standard defines privileging as “[the] process whereby the specific scope and content of patient care services (that is, clinical privileges) are authorized for a healthcare practitioner by a healthcare organization, based on evaluation of the individual’s credentials and performance.”
a. ACHC
b. DNV
c. TJC
TJC
What entity does “not specifically address” CVOs/ Delegations?
a. URAC
b. CMS
c. DNV
CMS
Which accreditation states “If the CVO achieves _____ certification for all delegated credentialing elements, the oversight responsibility is waived?
a. TJC
b. NCQA
c. AAAHC
NCQA
Temporary privileges cannot exceed ____ days
a. 60
b. 90
c. 120
120
An NCQA accredited organization’s credentialing process describes the monitoring of compliance with policies and procedures at least how often?
a. Annually
b. every 3 years
c. every 36 months
Annually
How the organization monitors its compliance with the policies and procedures at least annually and takes appropriate action when applicable is included in this organization’s credentialing process?
a. TJC
b. AAAHC
c. NCQA
NCQA
ACHC says evidence of continuing educational activities every _________ may be requested.
a. 2 years
b. 3 years
c. Time privileges are requested
2 years
What is the only accrediting organization that has standards regarding Credentialing System Controls?
a. TJC
b. AAAHC
c. NCQA
NCQA
How often an organization monitors its compliance with the policies and procedures?
a. at least every 2 years
b. at least annually
c. at least every 6 months
at least annually
Maintenance of continuing education every 2 years may be requested
a. TJC
b. NCQA
c. ACHC
ACHC
With this accreditation a criminal background is conducted on initial application and must request any criminal history for what length of time? Name accreditation and time frame
a. NCQA and annually
b. ACHC and 7-10 years
c. TJC and every 3 years
ACHC and 7-10 years
Criminal background checks but must be performed if required by State law for which of the following?
a. Medicare
b. URAC
c. TJC
Medicare
Which accreditors address CME?
a. ACHC, DNV, AAAHC
b. TJC, ACHC, DNV
c. TJC, DNV, AAAHC
TJC, ACHC, DNV
What entity requires a Criminal Background Check if it is “required by State Law”?
a. CMS
b. AAAHC
c. NCQA
CMS
Which accreditation obtains a criminal background check to hospital employees?
a. TJC
b. ACHC
c. CoPS
TJC
Name 3 organizations that do not specifically address criminal background checks.
a. Medicare CoPs, DNV, NCQA
b. URAC, Medicare CoPs, TJC
c. NCQA, URAC, AAAHC
NCQA, URAC, AAAHC
A professional credentialing organization, such as a CVO can be used to perform PSV, but the process for credentialing by the organization must reflect the requirements as stated in the standards.
a. TJC
b. NCQA
c. ACHC
ACHC
Under TJC the __________ states that organizations that use information from a CVO should have confidence in the completeness, accuracy, and timeliness of that information and outlines ten principles to evaluate such an agency.
a. CIHQ
b. CAMH
c. CAHP
CAMH
The organization’s credentialing process describes how primary source verification is received, dated, and stored.
a. TJC
b. NCQA
c. ACHC
NCQA
This accreditor is the only one with requirements for Credentialing System Controls.
a. NCQA
b. URAC
c. AAAHC
NCQA
The initial application must request information regarding any criminal history for 7-10 years.
a. TJC
b. NCQA
c. ACHC
ACHC
ACHC requires criminal history for what time frame?
a. 10-15 years
b. 5-10 years
c. 7-10 years
7-10 years
The organization maintains the right to approve, suspend or terminate practitioners and has responsibility for oversight of the delegated agency.
a. TJC
b. NCQA
c. ACHC
NCQA
ACHC Credentials Committee makes recommendations to the ____ within ____ days of receipt of a completed application.
a. MEC, 60
b. Person taking meeting minutes, 180
c. MEC, 30
MEC, 60
When is an application truly “completed”?
a. Once the MSP has reviewed the application
b. When the applicant signs the Attestation Pages
c. Once the application itself is complete, all PSV and information required has been obtained
Once the application itself is complete, all PSV and information required has been obtained
What is considered a completed Application?
a. A completed application is one in which the application itself is not only complete, but all primary source verification and information required by the medical staff bylaws, state and federal law, and accreditation requirements has been obtained
b. A completed application is one that has been submitted
c. A completed application is one that it has been signed and dated
A completed application is one in which the application itself is not only complete, but all primary source verification and information required by the medical staff bylaws, state and federal law, and accreditation requirements has been obtained
Although not required by accreditation standards, many hospital medical staff utilize a ____________ for evaluation of complete applications, reapplications and grants of privileges
a. Staff Committee
b. Credentialing Committee
c. Executive Committee
Credentialing Committee
ACHC states that recommendations to the Med Exec committee must be made ________days of receipt of a completed application
a. 45
b. 60
c. 30
60
NCQA views the approval decision made by the _______ committee as final decision?
a. Credentialing
b. Board
c. MEC
Credentialing
In non-departmentalized hospitals and those with a small medical staff, applications are presented directly to the MEC. The MEC makes its recommendations directly to the board.
_________ is the final authority?
a. The medical director
b. The department chair
c. The board
The board
The Governing Body is the ultimate authority in the hospital organization and is _____________ responsibility for everything that happens within the organization
a. ethically
b. legally
c. clinically
legally
In non-departmentalized hospitals, complete applications are presented directly to _____.
a. Governing Body
b. Credentialing Committee
c. MEC
MEC
One of the things Medicare CoP’s state is “if the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or ________.
a. Education
b. Psychology
c. Osteopathy
Osteopathy
What is the function of The Governing Body?
a. The Governing Body, or board, is the ultimate authority in the hospital organization and is legally responsible for everything that happens within the organization. Medical staff activities that fall under the board’s responsibility include credentialing and privileging issues (appointments, reappointments, terminations, and granting of clinical privileges), approval of bylaws for the medical staff organizations, oversight of functions delegated to the medical staff organization, and evaluation of the performance of the medical staff. The board must approve the processes for termination of medical staff membership and fair hearing procedures
b. The Governing Body process appointment and reappointments of medical staff members
c. The Governing Body must meet at least quarterly and as often as necessary to carry out its responsibilities
The Governing Body, or board, is the ultimate authority in the hospital organization and is legally responsible for everything that happens within the organization. Medical staff activities that fall under the board’s responsibility include credentialing and privileging issues (appointments, reappointments, terminations, and granting of clinical privileges), approval of bylaws for the medical staff organizations, oversight of functions delegated to the medical staff organization, and evaluation of the performance of the medical staff. The board must approve the processes for termination of medical staff membership and fair hearing procedures
What 2 accreditations do not address requirements regarding governing body authority?
a. URAC, NCQA
b. TJC, DNV
c. AAAHC, URAC
URAC, NCQA
According to URAC, the credentialing committee must have at least one member who what?
a. Has one other role within the specialty department
b. Is accountable for the quality of care provided
c. Does not have any other role in the management of the organization
Does not have any other role in the management of the organization
Which accreditor considers the date of the Credentialing Committee as the final decision date?
a. TJC
b. NCQA
c. ACHC
NCQA
What standard says that the committee must meet at least quarterly and as often as necessary to carry out its responsibilities.
a. NCQA
b. DNV
c. URAC
URAC
What accrediting body requires the organization to conduct ongoing monitoring that includes the collection and review of complaints?
a. TJC
b. CMS
c. NCQA
NCQA
The Board must approve the processes for termination of medical staff membership and __________ _________ procedures?
a. Privilege Request
b. Peer Review
c. Fair Hearing
Fair Hearing
Who must approve the processes for termination of medical staff membership and fair hearing procedures?
a. Chief of Staff
b. Board / Governing Body
c. Medical Executive Committee
Board / Governing Body
Which accreditation has a formal written grievance procedure?
a. URAC
b. ACHC
c. DNV
DNV
Both the specific complaint and the practitioner’s history of issues must be evaluated. There must be evidence of an evaluation of the history of complaints for all practitioners at least every six months, is stated by which accreditation?
a. NCQA
b. DNV
c. URAC
NCQA
Which standard mentions Interpretive Guidelines when discussing compliance with law?
a. DNV
b. Medicare CoP’s
c. NCQA
Medicare CoP’s
What 3 accrediting bodies require compliance with all applicable federal, state and local laws?
a. TJC, DNV, CMS
b. ACHC, URAC, AAAHC
c. DNV, URAC, AAAHC
DNV, URAC, AAAHC
Who states that the hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance?
a. TJC
b. URAC
c. CMS
CMS
Credentialing Committee decisions may be forwarded to a governing body for review, although _________ will still consider the date of the Credentialing Committee as the final decision date
a. URAC
b. NCQA
c. Medicare CoP’s
NCQA
Which accreditation holds its leaders responsible to be aware of and comply with local, State, and Federal regulations related to credentialing and privileging of practitioners?
a. TJC
b. NCQA
c. CoP’s
TJC
This standard at a minimum must review and send information to the distant-site’s telemed entity on all adverse events that result from a physician or practitioner’s provisions of telemed services, and on all complaints it has received.
a. TJC
b. Medicare CoP’s
c. ACHC / HFAP
ACHC / HFAP
TJC holds the hospitals governing body is ___________ to comply with applicable law & regulation while Leaders are to be ________.
a. Aware, Responsible
b. Responsible, Aware
c. Responsible, Not Applicable
Responsible, Aware
This accreditation allows complaints to be part of the recredentialing process through data collected regarding the provider’s performance within the organization?
a. AAAHC
b. NCQA
c. URAC
URAC
Which accreditation does not require verification of education/training if board certification is verified?”
a. TJC
b. NCQA
c. URAC
URAC
What accrediting body states the organization must only verify the highest level of credentials attained?
a. NCQA
b. URAC
c. CMS
NCQA
TJC considers _________ a primary source for verifying relevant training or experience at the time of appointment.
a. Applicant’s resume
b. Training program
c. Applicant’s previous employer
d. Personal reference
Training program
TJC allows which two sources to be used as DES for verification of Residency / Fellowship?
a. ABMS / FCVS
b. AMA / AAPA
c. AMA / AOA
AMA / AOA
Which standard or standards address compliance with State, Federal and Local Laws?
a. TJC
b. TJC, NCQA, URAC, AAAHC
c. All standards address this
All standards address this
Regarding “Telemedicine”, what accrediting body standards are a direct quotation of the CMS regulations?
a. DNV
b. ACHC
c. AAAHC
ACHC
Which standard states “criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges”, must be included in the bylaws?
a. TJC
b. DNV
c. CoP’s
CoP’s
In order to provide telemedicine services, one of TJC’s requirements is that the distant site practitioners has a license that is issued or recognized by the state in which?
a. The patient is receiving telemedicine services
b. The practitioner lives
c. The insurance company being paid is located
The patient is receiving telemedicine services
NCQA requires that corrections to incorrect information on an application be corrected by the applicant _______.
a. within 15 days of notice
b. as outlined in the policy
c. no later than 1 week
as outlined in the policy
This standard states that the governing body must assure that the medical staff has bylaws and that those bylaws comply with State and Federal law and the requirements of CoP’s?
a. AAAHC
b. Medicare
c. TJC
Medicare
Collected through the quality management program, the collected information regarding the participating provider’s performance is considered as a part of the recredentialing process of ______.
a. NCQA
b. AAAHC
c. URAC
URAC
Which standard states that you must confirm that the state board does verify a credential before relying on the board? Bonus: what is the time limit for this standard:
a. all standards address this; at time of appointment
b. NCQA, URAC; 180 days MCO; 120 days CVO
c. URAC; 180 days of credentialing decision
URAC; 180 days of credentialing decision
What is the distant site?
a. Place where the physician or practitioner is providing services
b. Place where the patient is
c. Place you want to travel to
Place where the physician or practitioner is providing services
With the exception of _____, the standards for the remaining accrediting bodies under “Compliance with Law” state there should be “compliance with all applicable federal, state and local laws.”
a. DNV
b. NCQA
c. ACHC
ACHC
Which 2 accreditations allow you to only verify the highest level of credentials attained when reviewing Residency and Fellowship?
a. TJC / Medicare
b. NCQA / URAC
c. ACHC / AAAHC
NCQA / URAC
The standards for both _____ and ____ state verify highest level of education/training and if the physician is Board certified, verification of the board certification meets the requirement.
a. TJC / NCQA
b. URAC / DNV
c. NCQA / URAC
NCQA / URAC
For Telemedicine, ACHC (HFAP) standards are a direct quotation of the _____ regulations?
a. NCQA
b. DNV
c. Medicare
Medicare
There are three accrediting bodies that address Telemedicine, one of the three specifically states the licensed practitioners providing patient care via telemedicine are subject to the credentialing and privileging processes of the originating site. Which one is that?
a. TJC
b. ACHC
c. DNV
TJC
When telemedicine services are furnished to the hospital’s patients through an agreement with a distant-site entity, the governing body of the originating site may choose, in lieu MS 6 to have its medical staff rely upon the decisions made by the distant site entity when recommending privileges.
a. DNV
b. Medicare CoP
c. TJC
DNV
What is an independent non-physician practitioner?
a. An independent non-physician practitioner is typically licensed by the state and can provide patient care, treatment, or services without supervision
b. An independent non-physician practitioner work only under the supervision of the physician employer
c. An independent non-physician practitioner is a dental assistant, private nurse, social worker, and private scrub technician
An independent non-physician practitioner is typically licensed by the state and can provide patient care, treatment, or services without supervision
ACHC recognizes ______________ as a designated equivalent source.
a. Fraud and Abuse Control Information Systems (FACIS)
b. A letter of recommendation
c. Peer Reference
Fraud and Abuse Control Information Systems (FACIS)
DNV standards do not use the language “designated equivalent sources” but does recognize _____________ profiles and ________ as acceptable verification sources
a. FACIS, AOA, ABMS
b. ABMS, AMA, ECFMG
c. AMA, AOA, ECFMG
AMA, AOA, ECFMG
The temporary privilege process may include a provision for a designee to act in _____________ the CEO or medical staff president when necessary
a. the absence of
b. in collaboration with
the absence of
_______________ states it is not necessary to obtain PSV of licensure if the volunteer LIP has _____________.
a. NCQA-only provided care to less than 10 patients
b. NCQA-not provided care, treatment, or services or services under the disaster privileges
c. TJC-not provided care, treatment, or services or services under the disaster privileges
TJC-not provided care, treatment, or services or services under the disaster privileges
Locum tenens or similar temporary staff may be used for a period not to exceed:
a. 2 months
b. 4 months
c. 6 months
6 months
During an emergency/disaster, which accreditation body states that a documented phone call is acceptable for primary source ID from the volunteer’s hospital?
a. TJC
b. ACHC
c. AAAHC
ACHC
__________ standards list 2 circumstances for which the granting of temporary privileges to a LIP would be acceptable (patient care need or a clean application)
a. TJC
b. DNV
c. ACHC
TJC
TJC standards allow the _______ (or his or her authorized designee) to grant temporary privileges based on the recommendation of the medical staff president or authorized designee.
a. CMO
b. CEO
c. COO
CEO
_____ standard allows the CEO to grant temporary privileges based on the recommendation of the president of the medical staff president or authorized designee.
a. TJC
b. URAC
c. DNV
TJC
Which organizations current competence process states data is collected on an ongoing basis and summarized at least (3) times during each three-year appointment cycle?
a. URAC
b. TJC
c. ACHC
ACHC
____________ states medical staff bylaws must identify the individual(s) responsible for granting disaster privileges.
a. NCQA
b. TJC
c. URAC
TJC
During a disaster, PSV of a license must begin as soon as the immediate situation is under control or within ___ hours from the time the volunteer LIP begins working at the hospital, whichever occurs first.
a. 24
b. 48
c. 72
72
According to ______________: Primary source verification of license must begin as soon as the immediate situation is under control or within 72 hours from the time the volunteer LIP begins working at the hospital, whichever occurs first
a. TJC
b. ACHC
c. DNV
TJC
During disasters, Disaster privileges may be granted to volunteer LIPs when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs for which accreditation?
a. TJC
b. DNV
c. ACHC
TJC
__________ states that primary source verification of license must begin as soon as the immediate situation is under control or within 72 hours from the time the volunteer physician and/or other licensed practitioner begins working at the hospital, whichever occurs first.
a. TJC
b. ACHC
c. DNV
TJC
Which accreditation states that if temporary privileges are granted, any limits to the number of specific patients who may be cared for must be identified?
a. DNV
b. ACHC
c. AAAHC
ACHC
_____ accrediting body states bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster.
a. DNV
b. HFAP
c. TJC
DNV
According to ______________: Bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster
a. AAAHC
b. ACHC
c. DNV
DNV
What are the designated sources for ACHC?
a. FSMB, FACIS, AMA, ECFMG, NPDB, ABMS, AOA
b. AMA, AOA
c. NPDB, ECFMG
FSMB, FACIS, AMA, ECFMG, NPDB, ABMS, AOA
When obtaining a primary source ID during a disaster, which accreditation states that a documented phone call from the volunteer’s hospital is acceptable?
a. ACHC
b. DNV
c. AAAHC
ACHC
Per TJC, __________ is information used in the decision to maintain, revise, or revoke existing privilege(s) prior to or at the time of renewal
a. QAPI
b. OPPE
c. CAMH
OPPE
During emergency / disaster, which standard accepts a documented phone call as a primary source ID from volunteer’s hospital?
a. TJC
b. NCQA
c. ACHC (HFAP)
ACHC (HFAP)
For AAAHC, documentation of current competence is obtained from?
a. Peers
b. Attestation of application
c. Primary Source Verification (PSV)
Peers
What regulation states that governing body must ensure that the competence criteria for selection of medical staff are individual character, competence, training, experience, and judgement?
a. Medicare CoP
b. DNV
c. AAAHC
Medicare CoP
TJC standards list two circumstances for which granting of temporary privileges to a LIP is acceptable. Which of the following is not one of the circumstances?
a. Applicant with a clean file waiting MEC and Board Approval
b. Locum Tenens
c. Important patient care need
Locum Tenens
Temporary privileges can be used in time of emergency and/or disaster. The hospital has a plan for dealing with clinical volunteers during emergency/disaster. This plan should provide for primary source ID from the volunteer’s hospital (A documented phone call is acceptable).
a. ACHC
b. DNV
c. TJC
ACHC
For current competence, the TJC states that the organized medical staff defines the frequency for OPPE data collection. However, the timeframe for review of data cannot exceed every _______?
a. 180 days
b. 2 years
c. 12 months
12 months
Who states locum tenens or similar temporary staff may be used for a period not to exceed (6) months?
a. ACHC
b. AAAHC
c. DNV
DNV
What accrediting organization does not use the language “des” but does recognize the AMA, AOA, profiles and the ECFMG as acceptable verification sources.
a. ACHC
b. URAC
c. DNV
DNV
Which 2 recognize FSMB as a designated equivalent source?
a. DNV, AAAHC
b. NCQA, ACHC
c. TJC, ACHC
TJC, ACHC
For ____ the Bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster.
a. TJC
b. DNV
c. ACHC
DNV
Which accreditation standards do not us the language “designated equivalent sources”, but does recognize AMA/AOA profiles and ECFMG as acceptable verification sources?
a. ACHC
b. DNV
c. URAC
DNV
Under the Facilities and Environment standards, a comprehensive written emergency and disaster preparedness plan to address internal and external emergencies is presented with _________?
a. DNV
b. NCQA
c. AAAHC
AAAHC
What 2 accrediting organizations do not specifically address an emergency management plan for privileges?
a. ACHC, URAC
b. TJC, DNV,
c. NCQA, URAC
NCQA, URAC
When granting temporary privileges which standard states “any limits to the number of specific patients who may be cared for must be identified.”
a. ACHC (HFAP)
b. DNV
c. NCQA
ACHC (HFAP)
This accrediting body is required to assess the practitioner’s ability to deliver care based on the credentialing information collected and verified prior to making a credentialing decision.
a. URAC
b. TJC
c. NCQA
NCQA
ACHC says the ________________ provide for the granting of temporary privileges.
a. CoP
b. Bylaws
c. Policies & Procedures
Bylaws
For ______, documentation of current competence is obtained from Peers.
a. ACHC
b. AAAHC
c. TJC
AAAHC
Standards do not use designated equivalent sources language, but it does recognize AMA/AOA and ECFMG as acceptable verification sources.
a. NCQA
b. TJC
c. DNV
DNV
Which accreditation collects ongoing professional practice evaluation data on an ongoing basis and summarized at least three (3) times during each three- year appointment cycle?
a. TJC
b. ACHC (HFAP)
c. DNV
ACHC (HFAP)
_____ states that an organization can rely on the verification activities of state licensing boards and if this is done, it should be noted in the Credentials file.
a. NCQA
b. AAAHC
c. URAC
URAC
The Medical Staff Bylaws provide for a Medical Staff Chief and/or the CEO to grant emergency privileges to practitioners to accomplish lifesaving procedures, within the scope of his/her license, if a credentialed practitioner with appropriate privileges is not available.
a. DNV
b. TJC
c. ACHC
ACHC
This accrediting body requires the medical staff to have a documented mechanism for oversight of the professional performance of volunteer physicians and other licensed practitioners who receive disaster privileges.
a. DNV
b. TJC
c. ACHC
TJC
Under the facilities and environment standards, a comprehensive written emergency and disaster preparedness plan to address internal and external emergencies is present for which accreditation?
a. DNV
b. URAC
c. AAAHC
AAAHC
Name the three accreditors that do not use the language “designated equivalent sources.”
a. TJC, NCQA, ACHC
b. DNV, URAC, AAAHC
c. NCQA, DNV, URAC
NCQA, DNV, URAC
Which accrediting body standard allows the CEO or his/her authorized designee to grant temporary privileges based on the recommendation of the president of the medical staff or authorized designee?
a. TJC
b. ACHC
c. DNV
TJC
Temporary privileges can be used in time of emergency and/or disaster under which accreditation?
a. TJC
b. ACHC (HFAP)
c. CoP
ACHC (HFAP)
DNV states that locum tenens or similar temporary staff may be used for a what length of time?
a. not to exceed 6 months
b. not to exceed 120 days
c. not to exceed 3 years
not to exceed 6 months
Per ACHC, Which of the following is an approved source for verifying Education
a. FSMB
b. ECFMG
c. NPDB
ECFMG
At an ACHC accredited hospital which of the following source is recognized for verifying actions against a physician’s medical license.
a. ACGME
b. ECFMG
c. FACIS
FACIS
NCQA only recognizes residency programs that have been accredited by which of the following?
a. NCQA
b. ACGME
c. AMA
ACGME
_______________ is defined as the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.
a. Electronic Communication
b. Telemedicine
c. Electronic Signature
Telemedicine
According to The TJC the originating site can fully ___________ and __________ the practitioner according to MS standards.
a. Audit and Delegate
b. Treatment and Services
c. Privilege and Credential
Privilege and Credential
___________ requires that the medical staff review and analyze all relevant information regarding current licensure, training, experience, current competence, and ability to perform the privileges requested
a. DNV
b. TJC
c. AAAHC
TJC
According to ___________ the medical staff must examine each individual practitioner’s qualifications and demonstrated competencies to perform each task/activity/privilege listed for the applicable scope of privileges for that category of practitioner
a. ACHC
b. TJC
c. NCQA
ACHC
A __________ can be utilized for items that are routine issues that do not require discussion. These items are voted on, without discussion, as a bundle
a. Passive Agenda
b. Consent Agenda
c. Memorandum of Actions
Consent Agenda
Distributing ___________ or __________ information is allowed prior to a meeting.
a. Confidential documents or peer reviews
b. Meeting notice or Statements
c. Agenda or attendance
Confidential documents or peer reviews
The DEA has a registration system in place which authorizes medical professionals, researchers, and manufacturers to access _____________ ?
a. The prescription drug monitoring program
b. Schedule I-V drugs
c. OTC medicines
Schedule I-V drugs
Authorized registrants received a __________, which is used for tracking controlled substances and as a unique identifier for anyone who can prescribe controlled substances
a. PIN Number
b. Password
c. DEA Number
DEA Number
Which accrediting body requires statement / information regarding felony convictions?
a. NCQA, ACHC, AAAHC
b. TJC, DNV, URAC
c. DNV, URAC, Medicare CoPs
NCQA, ACHC, AAAHC
According to ___________ the applicant must provide information regarding criminal convictions other than a minor traffic violation
a. URAC
b. AAAHC
c. TJC
AAAHC
Per _______ accreditation Education is verified by primary or secondary source on initial appointment
a. AAAHC
b. Medicare CoP
c. TJC
AAAHC
According to __________ history of education and professional training must be included on the credentialing application
a. AAAHC
b. URAC
c. TJC
URAC
All physicians or licensed practitioners providing patient care services via telemedicine are subject to the credentialing and privileging process of the ____________ _____________.
a. Distant Site
b. Both A & C
c. Originating Site
Originating Site
What organization states it must implement mechanisms for reviewing credentialing information for completeness, accuracy, and conflicting information.
a. DNV
b. NCQA
c. URAC
URAC
Which of the following is NOT part of what should be included in a record retention policy for storing credential files?
a. Who has access to credential files and under what circumstances
b. Where the keys to locked storage are kept
c. The preferred filing method for organizing documents
The preferred filing method for organizing documents
Which organization references CR 3 Element A Fact 2: DEA or CDS certificates must be verified in each state where the practitioner provides care to its members?
a. TJC
b. URAC
c. NCQA
NCQA
What organization states education must be verified within 180 days of credentialing decision?
a. URAC
b. NCQA
c. ACHC
URAC
When a practitioner and a patient are located in different states, the practitioner providing the patient care services must be?
a. Must have a license in the distant site and meet standards with state or local laws
b. Must be licensed and/or meet the other applicable standards that are required by state or local laws in both states
c. Must meet state or local laws with the originating site
Must be licensed and/or meet the other applicable standards that are required by state or local laws in both states
Some accreditors have standards specific to the review of information received in the credentialing and privileging process. Who does not?
a. CMS, AAAHC, DNV
b. All have standards or requirements for review of information
c. AAAHC, ACHC, TJC, DNV
CMS, AAAHC, DNV
What is one disadvantage of a healthcare organization using a centralized database for physician credentialing.
a. To many people accessing files and files can get misplaced
b. To many audits to make sure data integrity is not jeopardized
c. Increased risk of inappropriate dissemination of information
Increased risk of inappropriate dissemination of information
What is a Quorum?
a. The number of people that must be present to transact business
b. Establishing a meeting
c. Taking good minutes in a meeting
The number of people that must be present to transact business
What does NCQA state if a provider does not prescribe medications that require a DEA or CDS?
a. Provider should always have a DEA or CDS in he/she wants to be considered for credentialing
b. There must be a document in place to explain why the practitioner does not prescribe medications
c. Peer or covering colleague must prescribe on behalf of the practitioner without the certification
There must be a document in place to explain why the practitioner does not prescribe medications
Which accreditor verifies education with primary or secondary source on initial appointment?
a. DNV
b. TJC
c. AAAHC
AAAHC
What standard states a provider must provide information regarding criminal convictions other than minor traffic violations.
a. AAAHC
b. URAC
c. TJC
AAAHC
Which accreditation does not specifically address Telemedicine, BUT states if provided by contract, the governing body maintains responsibility?
a. URAC
b. AAAHC
c. DNV
AAAHC
URAC requires the organization to implement mechanisms for reviewing credentialing information for these 3 things?
a. continuing education, adherence to medical staff rules, compliance with licensure requirements
b. training, experience, ability to perform privilege
c. completeness, accuracy, conflicting information
Completeness, accuracy, conflicting information
A _______ _______ may be maintained showing who accessed the files, on what date, and for what reason?
a. Control Log
b. Record Retention Policy
c. Sign-in Sheet
Control Log
If a practitioner does not prescribe medications requiring a DEA or CDS certificate, _______ requires a documented process to require an explanation as to why the practitioner does not prescribe medications?
a. DNV
b. AAAHC
c. NCQA
NCQA
Sealed transcripts may be accepted if the organization shows evidence that it inspected the contents of the envelope and confirmed that practitioner completed the appropriate training program with what accreditation?
a. TJC
b. URAC
c. NCQA
NCQA
______ states that the applicant must provide information regarding criminal convictions other than minor traffic violations?
a. ACHC
b. NCQA
c. AAAHC
AAAHC
What accreditation standards are a direct quote of the CMS regulations regarding telemedicine?
a. ACHC, DNV
b. NCQA, URAC
c. ACHC, AAAHC
ACHC, DNV
Under NCQA, the _________________________ must, at a minimum, review the credentials for practitioners who do not meet established thresholds, give thoughtful consideration to the credentialing, information and document its credentialing, discussions in the meeting minutes
a. Medical Director
b. Board of Delegated Board Committee
c. Credentials Committee
Credentials Committee
Generating a report from a credentialing database containing information; comparing data from credentialing database and / or provider / contracting data elements; identifying outliers and correct discrepancies; generating a report to verify accuracy are steps that can be done on a periodic basis to ensure data ________________.
a. Security
b. Accuracy
c. Retention
Accuracy
Initial appointment to the medical staff and granting of initial clinical privileges shall include Primary source verification of current Federal Narcotics Registration Certificate (DEA) number (if required).
a. AAAHC
b. ACHC
c. DNV
DNV
History of education and professional training must be included on the credentialing application
a. URAC
b. NCQA
c. TJC
URAC
The application requests information regarding any criminal history and a criminal background investigation is conducted based on information provided in the application or as required by Federal and State regulations
a. NCQA
b. ACHC
c. AAAHC
ACHC
Many healthcare facilities utilize telemedicine providers to provide __________ that are not readily available to the facility or to provide specialty care consultations for isolated specialties or practitioners
a. Services
b. Admissions
c. Consults
Services
Regarding the analysis and use of information received, some __________ have standards specific to the review of the information received in the credentialing and recredentialing processes.
a. Regulations
b. MS Bylaws
c. Accreditors
Accreditors
It is a good idea to perform periodic ___________ to credentials files to verify compliance with the requirement of bylaws, accrediting agencies, and state and federal regulations
a. Checklists
b. Audits
c. Surveys
Audits
What accrediting organization requires a DEA to be verified on an ongoing basis (if application); at a minimum at expiration, appointment and reappointment
a. NCQA
b. DNV
c. AAAHC
AAAHC
What accrediting body requires the highest level of education or training to be verified?
a. URAC
b. DNV
c. NCQA
URAC
What accrediting body states that the applicant must provide information regarding criminal convictions other than minor traffic violations?
a. AAAHC
b. TJC
c. NCQA
AAAHC
What is telemedicine?
a. The use of medical information exchanged form one site to another via electronic communications
b. The use of electronic means for providers to provide consults to other facilities or providers
c. When medical information is reviewed by the patient via a patient portal
The use of medical information exchanged form one site to another via electronic communications
These accrediting bodies telemedicine standards are a direct quotation of the CMS regulations
a. ACHC, NCQA
b. NCQA, URAC
c. ACHC, DNV
ACHC, DNV
These organizations DO address analysis and use of information received in the credentialing & privileging process
a. CMS, DNV, URAC, AAAHC
b. ACHC, AAAHC, URAC, TJC
c. TJC, ACHC, NCQA, URAC
ACHC, AAAHC, URAC, TJC
The following are the typical elements included in credentialing and privileging databases:
a. Demographic, Addresses, Appointment, License, Certification, Medical Education/Training, CME, and Committees
b. Staff Membership, Malpractice Insurance, Appointment, Licenses, Peer Reviews, & Certifications
c. Demographic, Addresses, Committees, Malpractice Insurance, Privileges, FPPE & OPPE
Demographic, Addresses, Appointment, License, Certification, Medical Education/Training, CME, and Committees
This organization states that the practitioner application requests information regarding actions against DEA certificate or state CDS certificate
a. DNV
b. ACHC
c. TJC
ACHC
The NCQA states that any of the following can be used to verify education and training.
a. The primary source, the state licensing agency or specialty board, or registry, sealed transcripts may be accepted if the organization shows evidence that it inspected the contents of the envelope and confirmed that practitioner completed (graduated from) the appropriate training program, AMA Physician Masterfile
b. The school, AMA Physician Masterfile, ECFMG, AOA, physician Masterfile, and the AAPA profile for verification of PA education and NCCPA certification
c. Education is verified with primary or secondary source on initial appointment
The primary source, the state licensing agency or specialty board, or registry, sealed transcripts may be accepted if the organization shows evidence that it inspected the contents of the envelope and confirmed that practitioner completed (graduated from) the appropriate training program, AMA Physician Masterfile
This organization requires that the applicant must provide information regarding criminal convictions other than minor traffic violations
a. DNV
b. ACHC
c. AAAHC
AAAHC
When referencing telemedicine, who retains the responsibility for overseeing the safety and quality of services offered to its patients?
a. Distant Site
b. Originating Site
c. Healthcare Facility
Originating Site
When referencing analysis and use of information received, which standard states “files meeting established criteria may be reviewed and approved by the Credentialing Committee or by a medical director or designated physician?”
a. ACHC (HFAP)
b. NCQA
c. URAC
NCQA
In supporting departmental operations, how often should data be evaluated for accuracy? Bonus: Can you name 1 of the 4 process?
a. On a monthly basis
b. On an annual basis
c. On a periodic basis
On a periodic basis
This can be accomplished by the following process:
1. Generate report from credentialing database containing information
2. Compare data from credentialing database and/or provider/contracting data elements
3. Identify outliers and correct discrepancies
4. Generate report to verify accuracy
Which standard does not require verification of DEA certificate or state controlled dangerous substance certificate?
a. NCQA
b. DNV
c. URAC
URAC
Education verification not required if the practitioner is board certified, under what standard?
a. ACHC (HFAP)
b. DNV
c. URAC
URAC
Which accreditations do not address felony convictions?
a. TJC, DNV, URAC
b. TJC, DNV, URAC, CMS
c. NCQA, ACHC, AAAHC
TJC, DNV, URAC
Who always retains the responsibility for overseeing the safety and quality of services offered to its patients?
a. The Governing Board
b. The Originating Site
c. Medical Staff Committee
The Originating Site
Which two standards are a direct quote of CMS Regulations regarding telemedicine?
a. TJC, AAAHC
b. NCQA, URAC
c. ACHC, DNV
ACHC, DNV
Which entity states that information received must be consistently applied for each requesting practitioner?
a. HCQA
b. TJC
c. AAAHC
TJC
When using an electronic filing system, what allows for ease of sorting files at a later date?
a. A Control Log
b. Centralized Database
c. Consistent Naming Logic
Consistent Naming Logic
Which entity’s standard does not specifically address DEA?
a. NCQA
b. CMS
c. ACHC
CMS
Which standard requires PSV of education including AOA, AMA, and ECFMG, with documentation sufficient to support the requested privileges?
a. ACHC
b. CMS
c. HCQA
ACHC
Which standard states the applicant must provide information regarding criminal convictions other than minor traffic violations?
a. NCQA
b. ACHC
c. AAAHC
AAAHC
How is telemedicine defined?
a. Only for use when providers can’t reach patients at a clinic
b. A separate medical specialty
c. The use of medical information exchanged from one site to another via electronic communications to improve patients’ health status
The use of medical information exchanged from one site to another via electronic communications to improve patients’ health status
What accreditation states “ The Credentialing Committee must, at a minimum, review the credentials for practitioners who do not meet established thresholds, give thoughtful consideration to the credentialing information and document its credentialing discussions in the meeting minutes.”
a. TJC
b. NCQA
c. URAC
NCQA
It is a good idea to perform periodic audits for credentials files to verify compliance with the requirements of bylaws, accrediting agencies and __________?
a. Medical Staff Services
b. Medicare CoPs
c. State and Federal Regulations
State and Federal Regulations
For which accreditation does medical staff criteria for consideration of automatic suspension include when the practitioner’s DEA certificate has been revoked, suspended or on probation for any reason?
a. TJC
b. DNV
c. AAAHC
DNV
Which accrediting body states “ The organization need only verify the highest level of credentials attained.”
a. NCQA
b. ACHC
c. URAC
NCQA
Which accreditation states the application must include a statement regarding felony convictions.
a. TJC
b. NCQA
c. ACHC
NCQA
Which accreditation? “The medical staff must actually examine each individual practitioner’s qualifications and demonstrated competencies to perform each task/activity/privilege listed for the applicable scope of privileges for that category of practitioner.”
a. TJC
b. ACHC
c. NCQA
ACHC
If paper credentialing files are used, current files may be stored on-site, while historical files may be _____.
a. Shredded
b. Stored in boxes in a storage room
c. Stored Offsite
Stored Offsite
Primary source verification is required and includes: AMA, AOA, and ECFMG. Documentation regarding training and education must be sufficient to support requested privileges.
a. TJC
b. ACHC
c. NCQA
ACHC
If applicable, verify DEA/CDS on an ongoing basis; at a minimum, at expiration, appointment, and reappointment. Verify from primary or secondary source.
a. AAAHC
b. ACHC
c. NCQA
AAAHC
The application requests information regarding any criminal history and a criminal background investigation is conducted based on information provided in the application or as required by Federal and State regulations.
a. DNV
b. ACHC
c. AAAHC
ACHC
Which site always retains the responsibility for overseeing the safety and quality of services offered to its patients?
a. Originating Site
b. Distant Site
c. Originating Site and Distant Site
Originating Site
Name the 3 accrediting bodies that do not specifically address analysis and use of information received.
a. CMS, DNV, AAAHC
b. URAC, NCQA, CMS
c. TJC, CMS, DNV
CMS, DNV, AAAHC
When should essential data accuracy be evaluated?
a. Annually
b. Periodically
c. According to Medical Staff Bylaws
Periodically
The Credentialing Committee must, at a minimum, review the credentials for practitioners who do not meet established thresholds, consider the credentialing information and document its credentialing discussions in the meeting minutes. Files meeting established criteria may be reviewed and approved by the Credentialing Committee or by a medical director or designated physician
a. URAC
b. ACHC
c. NCQA
NCQA
TJC states: All physicians or licensed practitioners providing patient care services via telemedicine are subject to:
a. The credentialing and privileging processes of the originating site
b. The credentialing and privileging processes of the distant site
c. The credentialing and privileging processes of the billing site
The credentialing and privileging processes of the originating site
It is essential that _________________ be evaluated on a periodic basis
a. HIPAA Policies
b. Data Accuracy
c. Access Permissions
Data Accuracy
