CPMSM (TJC) EXAM STUDY GUIDE
2025/2026 ACCURATE QUESTIONS
WITH CORRECT DETAILED
ANSWERS || 100% GUARANTEED
PASS <RECENT VERSION>
1. HFAP stands for? - ANSWER ✓ Healthcare Facilities Accreditation
Program (Accrediting organization for AOA. Provides accreditation
programs for primarily osteopathic hospitals)
2. NPDB allowed practitioners to add statements to the report in what year? -
ANSWER ✓ 2004
3. HIPBD (Healthcare Integrity Protection Databank) began accepting reports
in what year? - ANSWER ✓ 1999
4. Practitioners may dispute NPDB report within how many days? - ANSWER
✓ 60
5. Organization can conduct accreditation surveys of hospital? - ANSWER ✓
Deemed status
6. NPDB opened and began collecting reports in what year? - ANSWER ✓
1990
7. TJC was formed in what year? - ANSWER ✓ 1951
8. Medicare COP was est. in what year? - ANSWER ✓ 1965
,9. HMO stands for? - ANSWER ✓ Health Maintenance Organization
10.Administrative Law definition? - ANSWER ✓ Regulations enacted by the
state and federal agencies to implement statues and regulatory requirements
"friend of the court"
11.Negligent Tort has 4 elements, what are they? - ANSWER ✓ 1. Duty to
exercise due care (standard of care) 2. Breach of duty 3. Injury 4. Proximate
cause
12.MCO stands for? - ANSWER ✓ Managed Care Organization
13.This healthcare regulatory created NPDB? - ANSWER ✓ Healthcare quality
improvement act (HCQIA) est. 1986
14.Per TJC, The governing body may delegate the Expedited credentialing
decision to a committee consisting of? - ANSWER ✓ At least 2 voting
governing body members
15.Per TJC, who can make recommendations to the governing body for medical
staff appointment? - ANSWER ✓ The medical staff
16.Per NCQA CR, the credentialing committee must utilize which process to
make recommendations regarding credentialing decisions? - ANSWER ✓
Peer review process
17.Per NCQA CR, the credentialing committee may review files or it may be
given to this authority to evaluate and approve files? - ANSWER ✓ The
medical director or approved qualified physician designee)
18.Per NCQA, the medical director's approval date is considered? - ANSWER
✓ The credentialing decision date.
19.Per URAC, the organization must provide written notification to providers
with how many business days of the determination? - ANSWER ✓ 10
,20.Per URAC, how often must an onsite review of delegated services happen? -
ANSWER ✓ At least every three years
21.Per URAC, how often must the delegation organization provide a report to
the credentialing committee? - ANSWER ✓ Annually
22.Per URAC, written notification of the credentialing determination to the
provide must be within how many days? - ANSWER ✓ 10 days
23.CMS conditions of participation for hospitals require that criteria for
selection to the medical staff include evaluation of five areas? - ANSWER ✓
CCJET
Character
Competency
Judgment
Experience
Training
24.How many board members must sit On an expedited privilege committee? -
ANSWER ✓ 2 members
25.Per TJC, who develops, adopts, amends bylaws? - ANSWER ✓ The medical
staff
26.Per TJC, who identifies any FPPE triggers that would indicate the need for
performance monitoring? - ANSWER ✓ The medical staff
27.Per TJC, who determines what OPPE performance data to collect? -
ANSWER ✓ The individual departments. The medical staff approves the
data collection.
28.Per NCQA, how frequent must the delegate submit a report to the client
(payer)? - ANSWER ✓ At least semiannually
29.Per AAAHC, who is responsible for the credentialing and reappointment
process and applying criteria to all individuals who provide pt care? -
ANSWER ✓ The governing body
, 30.Per HFAP, who develops an OPPE plan & FPPE process? - ANSWER ✓
The medical staff
31.Reappointment not to exceed 2 years for these 3 accreditiation? - ANSWER
✓ TJC, HFAP, CMS
32.This healthcare regulatory is a competition law (anti-competitive) -
ANSWER ✓ Sherman Anti-trust Act
33.Patient self-determination act definition? - ANSWER ✓ Patient allowed to
participate in treatment decisions
34.Which accredition requires that a recommendation be made to the medical
executive committee within 60 days of receipt of completed application? -
ANSWER ✓ HFAP
35.Which accreditation requires the applicant to be notified of initial
credentialing decisions and recredentialing denials within 60 days from cred
cmte decision? (Not required to notify practitioners of re-credentialing
approvals) - ANSWER ✓ NCQA
36.What must be reported to NPDB? - ANSWER ✓ •Medical malpractice
payments
•Federal and state licensure and certification actions
•Adverse clinical privileges actions
•Adverse professional society membership actions
•Negative actions or findings by private accreditation organizations and peer
review organizations
•Health care-related criminal convictions and civil judgments
•Exclusions from participation in a Federal or state health care program
(including Medicare and Medicaid exclusions)
•Other adjudicated actions or decisions
37.Reports must be submitted to the NPDB within? - ANSWER ✓ 30 days
38.According to TJC, which individual can provide a peer reference for a
physician assistant? - ANSWER ✓ Physician Assistant
2025/2026 ACCURATE QUESTIONS
WITH CORRECT DETAILED
ANSWERS || 100% GUARANTEED
PASS <RECENT VERSION>
1. HFAP stands for? - ANSWER ✓ Healthcare Facilities Accreditation
Program (Accrediting organization for AOA. Provides accreditation
programs for primarily osteopathic hospitals)
2. NPDB allowed practitioners to add statements to the report in what year? -
ANSWER ✓ 2004
3. HIPBD (Healthcare Integrity Protection Databank) began accepting reports
in what year? - ANSWER ✓ 1999
4. Practitioners may dispute NPDB report within how many days? - ANSWER
✓ 60
5. Organization can conduct accreditation surveys of hospital? - ANSWER ✓
Deemed status
6. NPDB opened and began collecting reports in what year? - ANSWER ✓
1990
7. TJC was formed in what year? - ANSWER ✓ 1951
8. Medicare COP was est. in what year? - ANSWER ✓ 1965
,9. HMO stands for? - ANSWER ✓ Health Maintenance Organization
10.Administrative Law definition? - ANSWER ✓ Regulations enacted by the
state and federal agencies to implement statues and regulatory requirements
"friend of the court"
11.Negligent Tort has 4 elements, what are they? - ANSWER ✓ 1. Duty to
exercise due care (standard of care) 2. Breach of duty 3. Injury 4. Proximate
cause
12.MCO stands for? - ANSWER ✓ Managed Care Organization
13.This healthcare regulatory created NPDB? - ANSWER ✓ Healthcare quality
improvement act (HCQIA) est. 1986
14.Per TJC, The governing body may delegate the Expedited credentialing
decision to a committee consisting of? - ANSWER ✓ At least 2 voting
governing body members
15.Per TJC, who can make recommendations to the governing body for medical
staff appointment? - ANSWER ✓ The medical staff
16.Per NCQA CR, the credentialing committee must utilize which process to
make recommendations regarding credentialing decisions? - ANSWER ✓
Peer review process
17.Per NCQA CR, the credentialing committee may review files or it may be
given to this authority to evaluate and approve files? - ANSWER ✓ The
medical director or approved qualified physician designee)
18.Per NCQA, the medical director's approval date is considered? - ANSWER
✓ The credentialing decision date.
19.Per URAC, the organization must provide written notification to providers
with how many business days of the determination? - ANSWER ✓ 10
,20.Per URAC, how often must an onsite review of delegated services happen? -
ANSWER ✓ At least every three years
21.Per URAC, how often must the delegation organization provide a report to
the credentialing committee? - ANSWER ✓ Annually
22.Per URAC, written notification of the credentialing determination to the
provide must be within how many days? - ANSWER ✓ 10 days
23.CMS conditions of participation for hospitals require that criteria for
selection to the medical staff include evaluation of five areas? - ANSWER ✓
CCJET
Character
Competency
Judgment
Experience
Training
24.How many board members must sit On an expedited privilege committee? -
ANSWER ✓ 2 members
25.Per TJC, who develops, adopts, amends bylaws? - ANSWER ✓ The medical
staff
26.Per TJC, who identifies any FPPE triggers that would indicate the need for
performance monitoring? - ANSWER ✓ The medical staff
27.Per TJC, who determines what OPPE performance data to collect? -
ANSWER ✓ The individual departments. The medical staff approves the
data collection.
28.Per NCQA, how frequent must the delegate submit a report to the client
(payer)? - ANSWER ✓ At least semiannually
29.Per AAAHC, who is responsible for the credentialing and reappointment
process and applying criteria to all individuals who provide pt care? -
ANSWER ✓ The governing body
, 30.Per HFAP, who develops an OPPE plan & FPPE process? - ANSWER ✓
The medical staff
31.Reappointment not to exceed 2 years for these 3 accreditiation? - ANSWER
✓ TJC, HFAP, CMS
32.This healthcare regulatory is a competition law (anti-competitive) -
ANSWER ✓ Sherman Anti-trust Act
33.Patient self-determination act definition? - ANSWER ✓ Patient allowed to
participate in treatment decisions
34.Which accredition requires that a recommendation be made to the medical
executive committee within 60 days of receipt of completed application? -
ANSWER ✓ HFAP
35.Which accreditation requires the applicant to be notified of initial
credentialing decisions and recredentialing denials within 60 days from cred
cmte decision? (Not required to notify practitioners of re-credentialing
approvals) - ANSWER ✓ NCQA
36.What must be reported to NPDB? - ANSWER ✓ •Medical malpractice
payments
•Federal and state licensure and certification actions
•Adverse clinical privileges actions
•Adverse professional society membership actions
•Negative actions or findings by private accreditation organizations and peer
review organizations
•Health care-related criminal convictions and civil judgments
•Exclusions from participation in a Federal or state health care program
(including Medicare and Medicaid exclusions)
•Other adjudicated actions or decisions
37.Reports must be submitted to the NPDB within? - ANSWER ✓ 30 days
38.According to TJC, which individual can provide a peer reference for a
physician assistant? - ANSWER ✓ Physician Assistant
