Study Session 3/4/2025

Question 1

ACHC states that the organization must obtain documentation regarding training and education ____________.

a. Sufficient to support requested privileges
b. To determine the privileges to be granted
c. For the highest level of education

Answer 1

Sufficient to support requested privileges

Question 2

AAAHC says a Medicare Certified ASC must have either a written transfer agreement with a hospital or to ensure that all physicians performing surgery in the ASC have ___________.

a. Relevant training or experience
b. Currently employment
c. Admitting privileges at a nearby hospital

Answer 2

Admitting privileges at a nearby hospital

Question 3

Regarding meeting management, if the chairman of record is unable to attend a meeting, an acting chairman ________________.

a. May be appointed on by vote before the meeting begins
b. May be appointed as the bylaws allow
c. May be appointed as the Policies & Procedures allow

Answer 3

May be appointed as the bylaws allow

Question 4

_______ states: “If there is not one peer with the same professional credential available, then a practitioner in the same practice area who can speak to the applicant / reapplicant’s professional competence and ethical standards can provide the reference.”

a. ACHC
b. DNV
c. TJC

Answer 4

ACHC

Question 5

_______ states: “For physician practitioners granted privileges only, the hospital’s governing body and its medical staff must exercise oversight, such as through credentialing and competency review, of those other physician practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff.”

a. DNV
b. ACHC
c. Medicare

Answer 5

Medicare

Question 6

______ states that experience is reviewed for continuity and relevance with documentation of any interruptions?

a. AAAHC
b. URAC
c. NCQA

Answer 6

AAAHC

Question 7

Work history is not specifically addressed with ________, but the application must include hospital affiliations and privileges and history of loss or limitation of privileges or disciplinary activity?

a. AAAHC
b. URAC
c. NCQA

Answer 7

URAC

Question 8

A ___________ _____________ can be utilized for items that are routine issues that do not require discussion during a meeting?

a. privileged motion
b. closed session
c. consent agenda

Answer 8

consent agenda

Question 9

______ states the organization must designate a Credentialing Committee that uses a peer review process to make recommendations regarding credentialing decisions?

a. TJC
b. ACHC
c. NCQA

Answer 9

NCQA

Question 10

______ states that all practitioners listed in the directory and are providing covered healthcare services to consumers are credentialed.

a. URAC
b. ACHC
c. Medicare

Answer 10

URAC

Question 11

When you hear “other than minor traffic violations” or “written emergency” or “cancellation” you think of?

a. NCQA
b. AAAHC
c. DNV

Answer 11

AAAHC

Question 12

When you hear “comparative” you think of?

a. DNV
b. ACHC
c. Medicare

Answer 12

DNV

Question 13

When you hear “laboratory” you think of?

a. URAC
b. DNV
c. Medicare

Answer 13

Medicare

Question 14

When you hear “clear report” or “sister hospital” or “medical related” you think of?

a. ACHC
b. DNV
c. TJC

Answer 14

ACHC

Question 15

When you hear “jurisdiction” or “cover sheet” you think of?

a. ACHC
b. URAC
c. NCQA

Answer 15

URAC

Question 16

When you hear “impaired” or “correct and complete” or “tort” or “Canada” you think of?

a. TJC
b. ACHC
c. NCQA

Answer 16

NCQA

Question 17

When you hear “geographic” you think of?

a. TJC
b. NCQA
c. URAC

Answer 17

TJC

Question 18

This accreditation states that the medical staff bylaws include criteria for determining the privileges to be granted and the AMA Master Profile is acceptable?

a. DNV
b. TJC
c. NCQA

Answer 18

DNV

Question 19

What standard does not specifically address that work history must be verified, but experience is required to be considered in making decisions.

a. DNV
b. TJC
c. Medicare

Answer 19

Medicare

Question 20

The responsibilities of the ______ include calling the meeting to order, keeping the meeting to its order of business, and handling discussion in an orderly way.

a. Committee
b. MSP
c. Chair

Answer 20

Chair

Question 21

What does the Medicare CoPs state about peer recommendations?

a. Must follow bylaws and CCJET is considered
b. Use of a peer group is recommended
c. Not specifically addressed

Answer 21

Not specifically addressed

Question 22

According to AAAHC who determines which other qualified professionals (AHPs) it wishes to allow on staff.

a. CEO, MEC
b. Governing body
c. Credential Committee

Answer 22

Governing body

Question 23

Which organization accepts sealed transcripts with an unbroken institution seal as primary source verification for training? This organization must document that it opened the envelope and confirmed completion of training?

a. TJC
b. DNV
c. NCQA

Answer 23

NCQA

Question 24

What organization states that on initial appointment experience is reviewed for continuity and relevance with documentation of any interruptions?

a. TJC
b. DNV
c. AAAHC

Answer 24

AAAHC

Question 25

What part of a meeting is referred to as the “blueprint of the meeting”? a. agenda b. scheduling c. meeting file

Answer 25

agenda

Question 26

Which organization discusses how for initial applicants, references should be obtained from the Residency Program Chair or a Department Chair? a. URAC b. TJC c. ACHC

Answer 26

ACHC

Question 27

Which profession does Medicare CoPs consider “more like non-physician practitioners", such as Physical Therapist, Occupational Therapist, and Speech Language Therapist? a. Chiropractors b. Pharmacists c. Ophthalmologists

Answer 27

Pharmacists

Question 28

TJC allows the use of the following designated equivalent sources for training verifications: a. AMA Physician Master Profile & AOA Physician Database b. FSMB & ECFMG c. All of the above

Answer 28

AMA Physician Master Profile & AOA Physician Database

Question 29

This organization requires a minimum of five years of relevant work history (work as a health professional including experience practicing as a non-physician health professional) must be obtained through the practitioner’s application or curriculum vitae: a. AAAHC b. DNV c. NCQA

Answer 29

NCQA

Question 30

Typical MSP meeting management functions include: a. Resource person and Facilitator b. Coordinator and Educator c. All of the above

Answer 30

All of the above

Question 31

This standard states “There is no specific requirement for peer recommendations.” a. URAC b. NCQA c. AAAHC

Answer 31

NCQA

Question 32

According to this standard, SR 5 The medical staff shall examine the credentials of all eligible candidates for medical staff membership / appointment and make recommendations to the governing body on the appointment of these candidates in accordance with law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. a. DNV b. TJC c. ACHC

Answer 32

DNV

Question 33

Medical staff must use peer recommendations in its consideration of recommendations for appointment and initial granting of privileges and in consideration of termination from the medical staff or revision / revocation of clinical privileges. a. TJC b. ACHC c. DNV

Answer 33

TJC

Question 34

At a minimum, physicians and dentists are credentialed and privileged. The board determines which other qualified professionals (AHPs) it wishes to allow on staff. a. DNV b. ACHC c. AAAHC

Answer 34

AAAHC

Question 35

Which organizations must obtain documentation regarding training and education sufficient to support requested privileges. a. DNV b. TJC c. ACHC

Answer 35

ACHC

Question 36

Which accreditor does not specifically address work history, the medical staff bylaws must include criteria for determining the privileges to be granted to individual practitioners, including experience. a. Medicare b. DNV c. AAAHC

Answer 36

DNV

Question 37

Verification of current and past hospital affiliations from the primary source is an important component of the credentialing process. While it is the practice of many hospitals to verify all past hospital affiliations, some hospitals verify only the past ______ years. a. 1-5 b. 5-10 c. 5-7

Answer 37

5-10

Question 38

Which of the following is an acceptable method for verifying documentation of training and education to support requested privileges according to ACHC standards? a. ECFMG, AMA Physicians Profile and AOA Official Osteopathic Physician Profile. b. Direct contact with Program Director, AMA Physicians Profile or AOA Official Osteopathic Physician Profile. c. Direct contact with program, AMA Physicians Profile or AOA Official Osteopathic Physician Profile.

Answer 38

Direct contact with program, AMA Physicians Profile or AOA Official Osteopathic Physician Profile.

Question 39

Which accreditor states; There is no specific requirement for peerrecommendations other than that a peer group makes the final credentialingdetermination. a. URAC b. NCQA c. AAAHC

Answer 39

URAC

Question 40

If an NCQA organization relies on the verification of training activities of a state licensing board, it must confirm: a. the state licensing board verified completion of training from the AMA Physician Masterfile (US / Puerto Rico) b. the state licensing agency performs primary source verification and provides documentation of a state statute requiring the source to perform PSV c. all levels of training were primary source verified

Answer 40

the state licensing agency performs primary source verification and provides documentation of a state statute requiring the source to perform PSV

Question 41

Although work history is not specifically addressed, the medical staff bylaws must include criteria for determining the privileges to be granted to individual practitioners, including experience refers to a. DNV b. URAC c. TJC

Answer 41

DNV

Question 42

If a motion is not seconded you can record the motion: a. verbatim b. record the number of votes in favor or against c. was lost due to a lack of a second or not record the motion at all

Answer 42

was lost due to a lack of a second or not record the motion at all

Question 43

TJC standards state, when renewing privileges, if there is insufficient data available, the _____________ uses and evaluates peer recommendations. a. Credentials Committee b. Clinical Service Chairperson c. Medical Staff

Answer 43

Medical Staff

Question 44

What is the training criteria that must be met for practitioners to serve in a hospital setting for Medicare CoPs? a. AMA (American Medical Association) b. CCJET (Character, Competence, Judgement, Experience and Training) c. ACGME (American College of Graduate Medical Education)

Answer 44

CCJET (Character, Competence, Judgement, Experience and Training)

Question 45

According to NCQA Standards, there are three highest three levels of education and training that need to be obtained by the Practitioner; What are those three levels? a. High School Transcripts, School Clubs Served, Sports b. Medical / Professional school, Residency, Board Certification c. Bachelors Degree, Masters Degree, Doctoral Degree

Answer 45

Medical / Professional school, Residency, Board Certification

Question 46

NCQA does not require primary source verification of work history. A minimum of ____ years of relevant work history (work as a health professional including experience practicing as a non- physician health professional) must be obtained through the practitioner’s application or curriculum vitae. a. 10 b. 4 c. 5

Answer 46

5

Question 47

Who is responsible for preparing the agenda and attachments. Coordinates follow-up activities. Reports appropriately and timely to the medical staff executive committee and governing board. a. Secretary of the Board b. President of the Board c. Coordinator

Answer 47

Coordinator

Question 48

What accreditation standard requires a statement regarding the physicians physical and mental health in relation to privileges requested? a. Medicare b. ACHC c. TJC

Answer 48

ACHC

Question 49

According to Medicare CoPs, all practitioners granted medical staff privileges must function under the bylaws, regulations and rules of the hospital’s medical staff. The privileges granted to an individual practitioner must be consistent with . a. Foreign scope of practice laws b. Federal scope of practice laws c. State scope of practice laws

Answer 49

State scope of practice laws