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Questions and Answers
If you have a question regarding whether or not information regarding a practitioner should be released to a third party, which of the following would be the best person to ask?
If you have a question regarding whether or not information regarding a practitioner should be released to a third party, which of the following would be the best person to ask?
- Director of Medical Records
- Chief of Staff
- Organization's attorney (correct)
Prior to releasing information to a third party regarding a practitioner, the organization should acquire:
Prior to releasing information to a third party regarding a practitioner, the organization should acquire:
- Approval from the organization's attorney
- A signed consent and release form (correct)
- A picture ID of the provider
If the CVO is not accredited by a nationally recognized organization, you must:
If the CVO is not accredited by a nationally recognized organization, you must:
- Perform an assessment of their turn-around times.
- Perform an assessment of the capability and quality of the CVO's work
- Perform an initial on-site visit of the CVO to assess their capabilities and quality of work. (correct)
What is the verification time limit for licensure per NCQA CVO standards?
What is the verification time limit for licensure per NCQA CVO standards?
According to The Joint Commission standards, initial appointments to the medical staff are not to exceed what time period?
According to The Joint Commission standards, initial appointments to the medical staff are not to exceed what time period?
At what times must the applicant's participation in continuing education be evaluated according to The Joint Commission standards?
At what times must the applicant's participation in continuing education be evaluated according to The Joint Commission standards?
According to NCQA standards, on initial application, the review of information on sanctions, restrictions on licensure and limitations on scope of practice must cover what time period?
According to NCQA standards, on initial application, the review of information on sanctions, restrictions on licensure and limitations on scope of practice must cover what time period?
At what times must the hospital query the NPDB for a physician, dentist, or other health care practitioner according to HCQIA?
At what times must the hospital query the NPDB for a physician, dentist, or other health care practitioner according to HCQIA?
What medical staff committee(s) are required by The Joint Commission hospital standards for the medical staff?
What medical staff committee(s) are required by The Joint Commission hospital standards for the medical staff?
The Joint Commission standards specifically require verification of medical malpractice insurance.
The Joint Commission standards specifically require verification of medical malpractice insurance.
At initial credentialing, URAC standards require primary source verification of what two elements?
At initial credentialing, URAC standards require primary source verification of what two elements?
Which specialty is most likely to be granted privileges for surgical management of congenital septal and valvular defects?
Which specialty is most likely to be granted privileges for surgical management of congenital septal and valvular defects?
URAC standards require the organization to provide a written notification to providers within how many business days of the credentialing determination?
URAC standards require the organization to provide a written notification to providers within how many business days of the credentialing determination?
According to NCQA standards, practitioners must be notified of their rights. Which of the following rights must they be notified of?
According to NCQA standards, practitioners must be notified of their rights. Which of the following rights must they be notified of?
When recredentialing, NCQA requires the organization to verify five factors. Which of the following is NOT one of them?
When recredentialing, NCQA requires the organization to verify five factors. Which of the following is NOT one of them?
According to NCQA, the ABMS Certified Doctor Verification Program, accessible through the ABMS website, is an acceptable source for verifying board certification of an MD.
According to NCQA, the ABMS Certified Doctor Verification Program, accessible through the ABMS website, is an acceptable source for verifying board certification of an MD.
The Joint Commission requires licensure to be verified with the primary source at what times?
The Joint Commission requires licensure to be verified with the primary source at what times?
According to The Joint Commission, the hospital must query the NPDB at what times?
According to The Joint Commission, the hospital must query the NPDB at what times?
Can the hospital accept an NPDB self-query performed by the physician to satisfy The Joint Commission's requirement for NPDB query?
Can the hospital accept an NPDB self-query performed by the physician to satisfy The Joint Commission's requirement for NPDB query?
According to NCQA standards, an organization must verify sanctions or limitations on licensure in each state where the practitioner holds or has ever held licensure.
According to NCQA standards, an organization must verify sanctions or limitations on licensure in each state where the practitioner holds or has ever held licensure.
When verifying licensure sanctions for physicians, NCQA allows verification with NPDB, HIPDB, the appropriate state agency(ies), and what other organization?
When verifying licensure sanctions for physicians, NCQA allows verification with NPDB, HIPDB, the appropriate state agency(ies), and what other organization?
According to NCQA standards, is verification from the ECFMG acceptable for education and training completed through the AMA's Fifth Pathway program?
According to NCQA standards, is verification from the ECFMG acceptable for education and training completed through the AMA's Fifth Pathway program?
According to AAAHC standards, can information from another healthcare organization that has performed PSV be accepted for credentialing?
According to AAAHC standards, can information from another healthcare organization that has performed PSV be accepted for credentialing?
According to The Joint Commission standards, peer recommendation must include written information regarding six elements. Which of the following is NOT one of the required elements?
According to The Joint Commission standards, peer recommendation must include written information regarding six elements. Which of the following is NOT one of the required elements?
What are the four appropriate sources of peer recommendations according to The Joint Commission standards?
What are the four appropriate sources of peer recommendations according to The Joint Commission standards?
Per NCQA, is there any situation in which it would be acceptable to use confirmation from the state licensing agency in lieu of verification of education?
Per NCQA, is there any situation in which it would be acceptable to use confirmation from the state licensing agency in lieu of verification of education?
According to URAC's health network standards, must licensure information from all states be included or only those in which the applicant will be providing services?
According to URAC's health network standards, must licensure information from all states be included or only those in which the applicant will be providing services?
Which of the following credentials must be tracked on an ongoing basis and why?
Which of the following credentials must be tracked on an ongoing basis and why?
For written verification received by the organization, does NCQA use the date the organization stamps the document as 'received' as the date of the official document?
For written verification received by the organization, does NCQA use the date the organization stamps the document as 'received' as the date of the official document?
For internet and electronic verification, if the source report does not generate a date, what date does NCQA use as the verification date?
For internet and electronic verification, if the source report does not generate a date, what date does NCQA use as the verification date?
The Joint Commission requires an initial application to be completed in 120 days.
The Joint Commission requires an initial application to be completed in 120 days.
NCQA sets a 120-day time limit for verification of licensure by a CVO.
NCQA sets a 120-day time limit for verification of licensure by a CVO.
According to TJC, all LIPs, APRNs, and PAs must be credentialed through the medical staff process.
According to TJC, all LIPs, APRNs, and PAs must be credentialed through the medical staff process.
NCQA allows the use of signature stamps on an application.
NCQA allows the use of signature stamps on an application.
A consent and release on an application allows an organization to obtain additional peer references than those provided by the applicant.
A consent and release on an application allows an organization to obtain additional peer references than those provided by the applicant.
When granting temporary hospital privileges, what minimum information do you need to verify?
When granting temporary hospital privileges, what minimum information do you need to verify?
Under what circumstances does NCQA allow exceptions to the 36-month recredentialing timeframe?
Under what circumstances does NCQA allow exceptions to the 36-month recredentialing timeframe?
Why is it important to check that the practitioner is not currently excluded, suspended, debarred, or ineligible to participate in Federal health care programs?
Why is it important to check that the practitioner is not currently excluded, suspended, debarred, or ineligible to participate in Federal health care programs?
Which of the following credentials must be tracked on an ongoing basis?
Which of the following credentials must be tracked on an ongoing basis?
According to NCQA standards, an organization that discovers sanction information, complaints, or adverse events regarding a practitioner must take what action?
According to NCQA standards, an organization that discovers sanction information, complaints, or adverse events regarding a practitioner must take what action?
What is the name of the entity established through the Health Care Quality Improvement Act of 1986?
What is the name of the entity established through the Health Care Quality Improvement Act of 1986?
When developing clinical privileging criteria, which of the following is important to evaluate?
When developing clinical privileging criteria, which of the following is important to evaluate?
What is the main reason for periodically assessing appropriateness of clinical privileges of each specialty?
What is the main reason for periodically assessing appropriateness of clinical privileges of each specialty?
Which of the following specialists is most likely to perform a PTCA?
Which of the following specialists is most likely to perform a PTCA?
The Joint Commission hospital standards require that clinical privileges are hospital specific and...
The Joint Commission hospital standards require that clinical privileges are hospital specific and...
Which of the following would be routinely performed by a cardiologist?
Which of the following would be routinely performed by a cardiologist?
Which NCQA-required committee makes recommendations regarding credentialing decisions?
Which NCQA-required committee makes recommendations regarding credentialing decisions?
HFAP standards require which three medical staff committees to be delineated in the medical staff structure?
HFAP standards require which three medical staff committees to be delineated in the medical staff structure?
How often does NCQA require that delegation reports be evaluated by the health plan?
How often does NCQA require that delegation reports be evaluated by the health plan?
Peer references should be obtained from:
Peer references should be obtained from:
NCQA recognizes which of the following as the final approval of an applicant who does not meet criteria for a clean file?
NCQA recognizes which of the following as the final approval of an applicant who does not meet criteria for a clean file?
If a medical staff member has privileges and/or medical staff appointment revoked, he/she must be:
If a medical staff member has privileges and/or medical staff appointment revoked, he/she must be:
Access to credentials files should be:
Access to credentials files should be:
Which of the following bodies approves clinical privileges?
Which of the following bodies approves clinical privileges?
What primary source verification is required by NCQA prior to provisional credentialing?
What primary source verification is required by NCQA prior to provisional credentialing?
According to The Joint Commission standards, initial appointments to the medical staff are made for a period of:
According to The Joint Commission standards, initial appointments to the medical staff are made for a period of:
According to The Joint Commission standards, temporary privileges may be granted by:
According to The Joint Commission standards, temporary privileges may be granted by:
According to The Joint Commission standards, which of the following items must be verified with a primary source?
According to The Joint Commission standards, which of the following items must be verified with a primary source?
According to NCQA standards, a copy of which of the following is acceptable verification of the document?
According to NCQA standards, a copy of which of the following is acceptable verification of the document?
According to NCQA standards, which is an acceptable source for primary source verification of Medicare and Medicaid sanction activity against physicians?
According to NCQA standards, which is an acceptable source for primary source verification of Medicare and Medicaid sanction activity against physicians?
According to The Joint Commission standards, which of the following is considered a designated equivalent source for verification of board certification?
According to The Joint Commission standards, which of the following is considered a designated equivalent source for verification of board certification?
Which of the following organizations have been recognized by The Joint Commission and NCQA to provide primary source verification of medical school graduation and residency training for U.S. graduates?
Which of the following organizations have been recognized by The Joint Commission and NCQA to provide primary source verification of medical school graduation and residency training for U.S. graduates?
According to NCQA standards, the application attestation statement must affirm that the application:
According to NCQA standards, the application attestation statement must affirm that the application:
According to The Joint Commission standards, medical staff bylaws should define:
According to The Joint Commission standards, medical staff bylaws should define:
According to The Joint Commission hospital standards, professional criteria for granting clinical privileges must include at least:
According to The Joint Commission hospital standards, professional criteria for granting clinical privileges must include at least:
The Joint Commission hospital standards require medical staff bylaws to include:
The Joint Commission hospital standards require medical staff bylaws to include:
According to NCQA standards, which of the following is an approved source for verification of board certification?
According to NCQA standards, which of the following is an approved source for verification of board certification?
According to The Joint Commission hospital standards, which of the following is a required component of the reappointment process?
According to The Joint Commission hospital standards, which of the following is a required component of the reappointment process?
According to URAC's health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following:
According to URAC's health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following:
According to AAAHC, which must be monitored on an ongoing basis?
According to AAAHC, which must be monitored on an ongoing basis?
According to The Joint Commission, a nurse practitioner functioning independently and providing a medical level of care must:
According to The Joint Commission, a nurse practitioner functioning independently and providing a medical level of care must:
According to The Joint Commission, which of the following is an acceptable source for verification for medical education of an international graduate?
According to The Joint Commission, which of the following is an acceptable source for verification for medical education of an international graduate?
When evaluating compliance with the required time-frame for recredentialing, NCQA counts the recredentialing period to the:
When evaluating compliance with the required time-frame for recredentialing, NCQA counts the recredentialing period to the:
NCQA standards require the organization to verify board certification at recredentialing:
NCQA standards require the organization to verify board certification at recredentialing:
To whom does the AAAHC give the responsibility for approving and ensuring compliance with policies and procedures related to credentialing, quality improvement, and risk management?
To whom does the AAAHC give the responsibility for approving and ensuring compliance with policies and procedures related to credentialing, quality improvement, and risk management?
In order for a healthcare facility to participate in the Medicare and Medicaid programs it must comply with the:
In order for a healthcare facility to participate in the Medicare and Medicaid programs it must comply with the:
According to The Joint Commission hospital standards, which of the following is an element of a self-governing medical staff?
According to The Joint Commission hospital standards, which of the following is an element of a self-governing medical staff?
Robert's Rules of order is an example of:
Robert's Rules of order is an example of:
The medical staff application should provide a chronological history of:
The medical staff application should provide a chronological history of:
In order to participate in a health plan, a provider must be accepted to the plan's:
In order to participate in a health plan, a provider must be accepted to the plan's:
In order for a physician to practice medicine in any state in the United States, he/she must possess:
In order for a physician to practice medicine in any state in the United States, he/she must possess:
Which of the following is considered post-graduate education?
Which of the following is considered post-graduate education?
Which of the following elements may not be used to evaluate credentials of applicants?
Which of the following elements may not be used to evaluate credentials of applicants?
The release of liability statement signed by the applicant for medical staff appointment should include:
The release of liability statement signed by the applicant for medical staff appointment should include:
Primary source verification is:
Primary source verification is:
Unexplained delays between graduation and medical school, incomplete training, and unexplained lapses in professional practice are examples of:
Unexplained delays between graduation and medical school, incomplete training, and unexplained lapses in professional practice are examples of:
When documenting a telephone conversation regarding primary source verification what should be documented?
When documenting a telephone conversation regarding primary source verification what should be documented?
According to HFAP standards, when confirming malpractice coverage the organization must:
According to HFAP standards, when confirming malpractice coverage the organization must:
Which of the following providers is considered a primary care physician (PCP)?
Which of the following providers is considered a primary care physician (PCP)?
Which body has the obligation to the community to assure that only appropriately educated, trained and currently competent practitioners are granted medical staff membership and clinical privileges?
Which body has the obligation to the community to assure that only appropriately educated, trained and currently competent practitioners are granted medical staff membership and clinical privileges?
When credentialing and privileging practitioners, it is appropriate to:
When credentialing and privileging practitioners, it is appropriate to:
Medical liability insurance should be held in what limits?
Medical liability insurance should be held in what limits?
Which of the following would be an appropriate question to ask an applicant for medical staff?
Which of the following would be an appropriate question to ask an applicant for medical staff?
The governing body delegates the responsibility of credentialing, recredentialing, and privileging to:
The governing body delegates the responsibility of credentialing, recredentialing, and privileging to:
Who should have access to medical staff meeting minutes?
Who should have access to medical staff meeting minutes?
In addition to conclusions, recommendations made, and actions taken, which of the following should always be documented in meeting minutes?
In addition to conclusions, recommendations made, and actions taken, which of the following should always be documented in meeting minutes?
Active, Associate, Courtesy, Honorary, and Consulting are examples of:
Active, Associate, Courtesy, Honorary, and Consulting are examples of:
Changes in medical staff bylaws are not final until formally approved by the:
Changes in medical staff bylaws are not final until formally approved by the:
What is the only hospital medical staff committee required by The Joint Commission hospital standards?
What is the only hospital medical staff committee required by The Joint Commission hospital standards?
The Healthcare Quality Improvement Act:
The Healthcare Quality Improvement Act:
Study Notes
Practitioner Exclusions & Federal Programs
- Checking practitioner eligibility is crucial to avoid facility accreditation loss.
- Required by Medicare Conditions of Participation for reimbursement of services.
Ongoing Credentialing Requirements
- Licensure, postgraduate education, and malpractice claims must be tracked continuously.
NCQA Standards & Practitioner Issues
- Organizations must investigate and act on sanctions or complaints regarding practitioners.
- Immediate action may include removing providers from panels or notifying them of investigations.
National Practitioner Data Bank
- Established under the Health Care Quality Improvement Act of 1986 to disclose malpractice and adverse action histories.
Clinical Privileging Criteria
- Evaluate standards of practice, such as specialty board recommendations and the number of providers within a specialty.
Periodic Assessment of Clinical Privileges
- Required for maintaining patient safety, ensuring practitioner competency, and adherence to care standards.
PTCA Specialists
- Interventional Cardiologists are the primary specialists performing Percutaneous Transluminal Coronary Angioplasty (PTCA).
Joint Commission Standards on Clinical Privileges
- Clinical privileges must be specific to the hospital and based on a practitioner's demonstrated competence.
Cardiology Procedures
- Cardiologists routinely conduct Transesophageal Echocardiography, not hysterectomies or urethral dilations.
NCQA Credentialing Committees
- The Medical Executive Committee, Quality Care Committee, and Credentialing Committee participate in credentialing recommendations.
HFAP Medical Staff Committees
- Must include a Medical Executive Committee, a Utilization Review Committee, and a Credentials Committee.
Health Plan Delegation Reports
- Evaluations must be conducted semi-annually as per NCQA requirements.
Peer References
- Should be obtained from practitioners in the same specialty or those who have referred to the applicant.
Final Approval for NCQA Applications
- The Credentialing Committee or Medical Director decides on applicants lacking clean files.
Due Process in Revocation of Privileges
- Medical staff members with revoked privileges must receive due process and be reported to the National Practitioner Data Bank.
Access to Credentialing Files
- Credential files access policies must be clearly described, with specific availability restrictions.
Approval of Clinical Privileges
- Clinical privileges are approved by the Credentials Committee, Medical Executive Committee, and Governing Body.
Primary Source Verification by NCQA
- Requires verification of licensure, malpractice history, and ability to perform requested privileges.
Joint Commission Initial Appointment Duration
- Appointments last a period determined by bylaws, not exceeding two years.
Granting of Temporary Privileges
- Temporary privileges can be granted by the CEO or authorized designee based on medical staff recommendations.
Primary Source Verification Items
- Must verify licensure, training, experience, competence, and sanctions related to Medicare/Medicaid.
Acceptable Verification Sources
- NCQA recognizes certain organizations like FSMB for primary verification of sanctions.
Joint Commission Designated Source for Board Certification
- The American Board of Medical Specialties (ABMS) is an acceptable source for board certification verification.
Medical School and Residency Training Verification
- Organizations like the American Medical Association Masterfile and FSMB are recognized for confirming graduate credentials.
Application Attestation Statement
- Must confirm that the application was completed by the provider and is accurate.
Medical Staff Bylaws Determination
- Bylaws must outline appointment mechanisms, staff structure, and emergency call scheduling.
Professional Criteria for Privileges
- Must include training, experience, licensure, competence, and verification of prior malpractice claims.
Medical Staff Bylaws Inclusion
- Bylaws must define review processes for quality of care and removal of executive staff.
Verification of Board Certification
- Conducted for all practitioners during recredentialing as per NCQA standards.
Reappointment Process Components
- Must include health status documentation and Medicare/Medicaid sanctions query.
URAC Health Network Standards
- Applications must include state licensure and a comprehensive list of hospital affiliations.
Ongoing Monitoring Requirements
- NCQA standards necessitate monitoring current licensure and malpractice coverage.
Nurse Practitioners and Medical Privileges
- Independent nurse practitioners must possess clinical privileges and have job descriptions.
Education Verification for International Graduates
- Education credentials must be verified through the Education Commission for Foreign Medical Graduates.
NCQA Recredentialing Timeframes
- Counts recredentialing periods to the year, not the month or week.
Credentialing Responsibility
- The governing body delegates credentialing and privileging to the medical staff.
Accessing Medical Staff Meeting Minutes
- Access should align with documented policies and may include governing body members.
Documentation in Meeting Minutes
- Must include names, titles of attendees, date of the next meeting, and any necessary follow-ups.
Classification of Medical Staff Membership
- Examples include Active, Associate, and Consulting membership categories.
Changes in Medical Staff Bylaws
- Require approval from the governing body to be finalized.
Joint Commission Required Committee
- Only the Credentials Committee is mandated as per hospital standards.
Quality Improvement Act Liability Protections
- Provides immunity for good faith peer review activities to prevent lawsuits.
Release of Practitioner Information
- Requires a signed consent and release form before third-party disclosure.
CVO Accreditation Assessment
- Non-accredited CVOs necessitate initial on-site evaluations for their quality and capabilities.
Verification Time Limit for Licensure
- Set to a maximum of 180 days per NCQA CVO standards.
Initial Staff Appointments Duration Maximum
- Set by The Joint Commission standards at not exceeding three years.
Continuing Education Evaluation for Reappointment
- Assessed during the initial appointment and reappointment phases.
Sanction Review Period
- NCQA mandates review for sanctions covering the most recent five years upon initial applications.### HCQIA Query Requirements
- Hospitals must query the National Practitioner Data Bank (NPDB) at the initial granting of privileges, renewal of privileges, and when a new privilege is requested.
- A practitioner’s application for new privileges also triggers the need for an NPDB query.
Joint Commission Standards
- Required medical staff committees: Board, Medical Executive Committee (MEC), and Credentials Committee.
- The Joint Commission does not require verification of medical malpractice insurance.
URAC Standards for Initial Credentialing
- URAC mandates primary source verification of board certification (or highest level of education) and state licensure during initial credentialing.
- Providers must be notified in writing within 10 business days of credentialing determinations.
NCQA Standards for Practitioner's Rights
- Practitioners must be informed of their rights to review submitted information, correct erroneous information, inquire about the status of their application, and receive notification of these rights.
Recredentialing Verification
- NCQA requires verification of licensure, board certification (if applicable), history of malpractice claims, and licensure sanctions for the past five years during recredentialing.
- Verification from the ABMS Certified Doctor Verification Program is not considered primary source verification.
Peer Recommendations
- Peer recommendations must address professionalism, medical knowledge, technical skills, clinical judgment, interpersonal skills, and communication skills.
- Acceptable sources for peer recommendations include organized performance improvement committees and reference letters from knowledgeable peers.
Acceptable Verification Methods
- Confirmation from the state licensing agency may substitute for verification of education and residency if the agency conducts primary source verification.
- Ongoing tracking of state licensure is essential, as licensure can expire, unlike other static credentials.
NCQA Standards on Document Dates
- The date on the official document is used to assess timeliness, rather than the date the organization receives it.
- For electronic verification, if a source report does not generate a date, NCQA uses the date noted by organizational staff during verification.
Credentialing Process and Time Limits
- Initial applications are not bound to a 120-day limit set by The Joint Commission; the hospital determines its own processing time.
- NCQA stipulates a 120-day time limit for verification of licensure by a Credentialing Verification Organization (CVO).
Temporary Privileges and Exceptions
- Minimum verification for temporary hospital privileges includes current licensure, NPDB query, professional liability insurance, and clinical competence verification.
- Exceptions to the standard 36-month recredentialing timeframe can occur for providers on military or maternity leave, requiring valid licensure verification before they resume care.
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Test your knowledge with this practice exam flashcard set for the CPCS 2018 certification. Each flashcard provides crucial information regarding the accreditation of health care practitioners and their eligibility to participate in Federal health care programs. Prepare effectively for your upcoming certification exam with these key concepts.
