CPMSM QUESTIONS AND ANSWERS
HFAP - Answers :Refers to a CVO as a Professional Credentialing Organization (PCO)
HFAP Appointment time frame - Answers :2 years
TJC Appointment time frame - Answers :No longer than every 2 years
NCQA Appointment time frame - Answers :3 years (to the month)
URAC Appointment time frame - Answers :3 years
AAAHC Appointment time frame - Answers :3 years
Attestation Statement - Answers :TJC and Medicare do not specifically address, URAC
allows electronic signature, all others require.
Board Certification Verification - Answers :Not specifically required (only highest level of
education) has to be verified within 180 days per NCQA or 120 days if CVO is verifying.
CME - Answers :HFAP may request every 2 years. TJC requires documentation. No
others require.
TJC views of Competence - Answers :Monitoring of provider competence must be
ongoing.
URAC and NCQA views of Competence - Answers :Monitoring of provider competence
must be ongoing and organization must have policies for monitoring in place.
HFAP view of Competence - Answers :Competence can be monitored by proof of
procedures performed. This can be done by the provider providing their procedure logs.
AAAHC view of Competence - Answers :Competence can be monitored by provided
documentation of competency.
Medicare view of Competence - Answers :Governing body must verify character,
competence, judgement, education, and training.
Felony Conviction - Answers :Only addressed by a question or statement of provider
application by NCAQ, HFAP, and AAAHC
NCQA and URAC on Education - Answers :Only highest level of education verified.
TJC and Medicare - Answers :Does no address Medicare and Medicaid sanctions.
,NPDB - Answers :NCQA and URAC do not require it but it is an acceptable verification
of sanctions. All other organizations require.
Site Visit - Answers :NCQA is the only organization that requires a site visit under
certain circumstances.
Temporary Privileges - Answers :AAAHC and Medicare do not specifically address.
Temporary Privileges granting requirements - Answers :This type of privilege can be
granted by the CEO upon recommendation from the Chief of Staff or authorized
designee as long as license, malpractice coverage, and NPDB have been verified.
NCQA specifically says Provisional (Temporary) Privileges - Answers :Can be granted
by Chief Medical Official as long as their is a policy in place, the application is clean,
and the privileges can be granted for no more than 60 days.
Work History - Answers :URAC and Medicare do not address, NCAQ: History must be
verified and any gaps of 6 months or greater require explanation.
TJC & HFAP Work History - Answers :require the question to be asked: Has the
provider ever been terminated or suspended and NPDB must be compared to answer of
the above question.
AAAHC Work History - Answers :Any interruptions in employment must be accounted
for.
Health Status Form - Answers :All organizations require a current statement of ability to
perform as a provider. HFAP requires it to be documented from references.
Views on Allied Health Professionals - Answers :NCQA: Credentials all providers the
same
URAC: Adds that they must be listed in directory
TJC & AAAHC: Say that MCO must distinguish providers as those with and without the
need for supervision
Medicare: Can grant privileges with or without Medical Staff rights.
Disaster Plan - Answers :TJC, HFAP, AAAHC require groups/organizations to have the
plan documented and in place.
DEA Verification - Answers :Copies can be accepted, ensure there are no challenges to
the certificate.
Licensure - Answers :Medicare: does not specifically address sanctions URAC: states
that it has to be verified in a 6 month time frame.
NCQA: Verified within 180 days (or 120 for CVO)
All organizations require that the monitoring of licensure be ongoing.
, Malpractice - Answers :AAAHC, TJC, Medicare: Not fully addressed but states if bylaws
require verification or proof of coverage, documentation must be obtained. All other
organizations require proof and verification.
Malpractice History - Answers :NCQA: Pulled and verified with in the correct time
frames (180 days or 120 days if CVO)
URAC: 6 month time frame
All require at minimum to verify history for the last 5 years.
Accountable Care Organization - Answers :Pt Centered and includes offices, hospitals,
nursing homes. The healthcare organization is characterized by a payment and care
delivery model that seeks to tie provider reimbursements to quality metrics and
reductions in the total cost of care for patients. Patients are assigned to specific
providers.
EMTALA - Answers :Emergency Medical Treatment and Active Labor Act -Must be an
emergency
-Must screen to see if it is a true emergency
-Stabilize pt prior to transfer
-Must have "on call" list. (Medicare does not specify hoe many days must be covered)
Security Rule - Answers :The Security Standards for the Protection of Electronic
Protected Health Information, commonly known as the HIPAA. Security Rule,
establishes national standards for securing patient data that is stored or transferred
electronically.
Sherman Antitrust Act (1980) - Answers :Known as "competition law" states
-Can not monopolize services
-Must have exclusive contract to limit practitioners
-Can not pay practitioners for using your services, or "incentivizing" provider to use your
facilities or services.
PSQIP - Answers :The Patient Safety and Quality Improvement Act of 2005: Pub.L.
109-41, 42 U.S.C. ch. 6A subch. VII part C, established a system of patient safety
organizations and a national patient safety database. To encourage reporting and broad
discussion of adverse events, near misses, and dangerous conditions, it also
established privilege and confidentiality protections for Patient Safety Work Product.
The PSQIA was introduced by Sen. Jim Jeffords. It passed in the Senate July 21, 2005
by unanimous consent, and passed the House of Representatives on July 27, 2005 with
428 Ayes, 3 Nays, and 2 Present/Not Voting
CVO Audits - Answers :-10 credentialing and 10 re-credentialing
-Pre-delegation Audit
-look at files, policies, and procedures
-Must provide semi annual reports
HFAP - Answers :Refers to a CVO as a Professional Credentialing Organization (PCO)
HFAP Appointment time frame - Answers :2 years
TJC Appointment time frame - Answers :No longer than every 2 years
NCQA Appointment time frame - Answers :3 years (to the month)
URAC Appointment time frame - Answers :3 years
AAAHC Appointment time frame - Answers :3 years
Attestation Statement - Answers :TJC and Medicare do not specifically address, URAC
allows electronic signature, all others require.
Board Certification Verification - Answers :Not specifically required (only highest level of
education) has to be verified within 180 days per NCQA or 120 days if CVO is verifying.
CME - Answers :HFAP may request every 2 years. TJC requires documentation. No
others require.
TJC views of Competence - Answers :Monitoring of provider competence must be
ongoing.
URAC and NCQA views of Competence - Answers :Monitoring of provider competence
must be ongoing and organization must have policies for monitoring in place.
HFAP view of Competence - Answers :Competence can be monitored by proof of
procedures performed. This can be done by the provider providing their procedure logs.
AAAHC view of Competence - Answers :Competence can be monitored by provided
documentation of competency.
Medicare view of Competence - Answers :Governing body must verify character,
competence, judgement, education, and training.
Felony Conviction - Answers :Only addressed by a question or statement of provider
application by NCAQ, HFAP, and AAAHC
NCQA and URAC on Education - Answers :Only highest level of education verified.
TJC and Medicare - Answers :Does no address Medicare and Medicaid sanctions.
,NPDB - Answers :NCQA and URAC do not require it but it is an acceptable verification
of sanctions. All other organizations require.
Site Visit - Answers :NCQA is the only organization that requires a site visit under
certain circumstances.
Temporary Privileges - Answers :AAAHC and Medicare do not specifically address.
Temporary Privileges granting requirements - Answers :This type of privilege can be
granted by the CEO upon recommendation from the Chief of Staff or authorized
designee as long as license, malpractice coverage, and NPDB have been verified.
NCQA specifically says Provisional (Temporary) Privileges - Answers :Can be granted
by Chief Medical Official as long as their is a policy in place, the application is clean,
and the privileges can be granted for no more than 60 days.
Work History - Answers :URAC and Medicare do not address, NCAQ: History must be
verified and any gaps of 6 months or greater require explanation.
TJC & HFAP Work History - Answers :require the question to be asked: Has the
provider ever been terminated or suspended and NPDB must be compared to answer of
the above question.
AAAHC Work History - Answers :Any interruptions in employment must be accounted
for.
Health Status Form - Answers :All organizations require a current statement of ability to
perform as a provider. HFAP requires it to be documented from references.
Views on Allied Health Professionals - Answers :NCQA: Credentials all providers the
same
URAC: Adds that they must be listed in directory
TJC & AAAHC: Say that MCO must distinguish providers as those with and without the
need for supervision
Medicare: Can grant privileges with or without Medical Staff rights.
Disaster Plan - Answers :TJC, HFAP, AAAHC require groups/organizations to have the
plan documented and in place.
DEA Verification - Answers :Copies can be accepted, ensure there are no challenges to
the certificate.
Licensure - Answers :Medicare: does not specifically address sanctions URAC: states
that it has to be verified in a 6 month time frame.
NCQA: Verified within 180 days (or 120 for CVO)
All organizations require that the monitoring of licensure be ongoing.
, Malpractice - Answers :AAAHC, TJC, Medicare: Not fully addressed but states if bylaws
require verification or proof of coverage, documentation must be obtained. All other
organizations require proof and verification.
Malpractice History - Answers :NCQA: Pulled and verified with in the correct time
frames (180 days or 120 days if CVO)
URAC: 6 month time frame
All require at minimum to verify history for the last 5 years.
Accountable Care Organization - Answers :Pt Centered and includes offices, hospitals,
nursing homes. The healthcare organization is characterized by a payment and care
delivery model that seeks to tie provider reimbursements to quality metrics and
reductions in the total cost of care for patients. Patients are assigned to specific
providers.
EMTALA - Answers :Emergency Medical Treatment and Active Labor Act -Must be an
emergency
-Must screen to see if it is a true emergency
-Stabilize pt prior to transfer
-Must have "on call" list. (Medicare does not specify hoe many days must be covered)
Security Rule - Answers :The Security Standards for the Protection of Electronic
Protected Health Information, commonly known as the HIPAA. Security Rule,
establishes national standards for securing patient data that is stored or transferred
electronically.
Sherman Antitrust Act (1980) - Answers :Known as "competition law" states
-Can not monopolize services
-Must have exclusive contract to limit practitioners
-Can not pay practitioners for using your services, or "incentivizing" provider to use your
facilities or services.
PSQIP - Answers :The Patient Safety and Quality Improvement Act of 2005: Pub.L.
109-41, 42 U.S.C. ch. 6A subch. VII part C, established a system of patient safety
organizations and a national patient safety database. To encourage reporting and broad
discussion of adverse events, near misses, and dangerous conditions, it also
established privilege and confidentiality protections for Patient Safety Work Product.
The PSQIA was introduced by Sen. Jim Jeffords. It passed in the Senate July 21, 2005
by unanimous consent, and passed the House of Representatives on July 27, 2005 with
428 Ayes, 3 Nays, and 2 Present/Not Voting
CVO Audits - Answers :-10 credentialing and 10 re-credentialing
-Pre-delegation Audit
-look at files, policies, and procedures
-Must provide semi annual reports
