CPMSM - Study Guide Material with
Complete Solutions
According to TJC, when do you need to contact other facilities directly with regard to
work history? - Answers-IF applicants answers on the application differ from information
on NPDB
According to TJC, which three privileging events require NPDB query? - Answers-Initial
Renewal
New privilege request
Any required committees for AAAHC? - Answers-no
Are sanctions specifically addressed by DNV? - Answers-No
Can NCQA credentials committee meetings and decision making be conducted only
through email? - Answers-No
CMS regulations require that medical staff bylaws include what information pertaining to
each category of the medical staff? - Answers-duties and privileges
Do CoPs have required medical staff committees? - Answers-no
Do Medicare CoPs specifically state that work history must be verified? - Answers-No
But experience is required to be considered in making decision
Do providers with refer and follow status have admitting privileges/ordering privileges
within the hospital? - Answers-No
Do TJC, CoP or NCQA standards require criminal background checks? - Answers-No
Does HFAP have any provisions for LIP health? - Answers-no
Does TJC have a requirement for verification of liability coverage? - Answers-None
Does TJC recommend or require that hospitals base evaluations for competence on the
six general areas? - Answers-Recommend
Duties of MEC to be documented in bylaws? - Answers-Acts on behalf of medical staff
between med staff meetings
Mechanism for recommending terminations
If question about ability to perform privileges granted, must request evaluation
Recommend to gov body the structure of med staff
,Recommend to gov body the process for reviewing credentials and delineating
privileges
EMTALA is a section of which ERISA (Employment Retirement Income Security Act),
Internal Revenue Code and Public Health Service Act? - Answers-COBRA
For CoP, surgical privileges must be delineated for all practitioners performing surgery
in accordance with... - Answers-the competencies of each practitioner
For dietary services. how often must the therapeutic diet manual be reviewed? -
Answers-Revision less than five years old.
Must be available for all medical, nursing and food service personnel.
For Medicare deemed facilities, the delegation of credentialing agreement must include
what clause? - Answers-Adhere to Medicare regulations
For non TJC hospital, what are two options for telemedicine credentialing? - Answers-
Verify that all LIPs have appropriate privileges by obtaining copy of privileges
Include in contract that the organization will ensure that services by LIPs are within
scope
For practitioners with federal tort coverage, what is required for liability verification? -
Answers-Copy of Federal Tort letter or
Attestation from provider stating that they hold such coverage
For TJC deemed status hospitals, what are two requirements of the originating site
agreement? - Answers-Distant site is a contractor of services to hospital
Distant site furnishes services in manner permitting orig. site to be compliance with
CoPs
For TJC, does "privileges" refer to duties and prerogatives of each category or the
clinical privileges to provide care? - Answers-Duties and prerogatives
For which accreditation, do the following practitioners need *not* to be credentialed
including:
-exclusively in the inpatient setting caring for organization members only in the hospital
setting
-practice exclusively in free-standing setting for members directed to facility
-pharmacists working for a PBM (pharmacy benefits management) organization for UM
functions
-locum tenens working less than 90 days
-rental network practitioners providing out of area care - Answers-NCQA
For which conditions does HFAP require consultations of patients? - Answers-Critically
ill patients
, Patients who have poor risk for surgery
Patients with difficult or obscure diagnoses
How does HCQIA define recommendations that adversely affect a providers privileges
or med staff appointment? - Answers-Reducing, restricting, suspending, revoking,
denying or failing to renew
How frequently must bylaws be reviewed under HFAP? - Answers-at least every two
years
How frequently under HFAP must the medical staff provide evaluations of
improvements in clinical care? - Answers-Annually
How long does a provider have to request a hearing after being notified of an adverse
recommendation? - Answers-30 days
How many days of suspension of privileges/membership would lead trigger a hearing? -
Answers-Greater than 14 days
How many medical staff members comprise a Bylaws Committee? - Answers-5
At least five active medical staff
How many medical staff members comprise a Credentials Committee? - Answers-5
At least five active medical staff
How many medical staff members must serve on a Medical Records Committee? -
Answers-1
At least one active medical staff
How many medical staff members must serve on a Pharmacy & Therapeutics
Committee? - Answers-5
At least five active medical staff
How many medical staff members must serve on a Utilization Review Committee? -
Answers-1
At least one active medical staff
How many medical staff members must serve on an Infection Control Committee? -
Answers-3
At least three active medical staff
Complete Solutions
According to TJC, when do you need to contact other facilities directly with regard to
work history? - Answers-IF applicants answers on the application differ from information
on NPDB
According to TJC, which three privileging events require NPDB query? - Answers-Initial
Renewal
New privilege request
Any required committees for AAAHC? - Answers-no
Are sanctions specifically addressed by DNV? - Answers-No
Can NCQA credentials committee meetings and decision making be conducted only
through email? - Answers-No
CMS regulations require that medical staff bylaws include what information pertaining to
each category of the medical staff? - Answers-duties and privileges
Do CoPs have required medical staff committees? - Answers-no
Do Medicare CoPs specifically state that work history must be verified? - Answers-No
But experience is required to be considered in making decision
Do providers with refer and follow status have admitting privileges/ordering privileges
within the hospital? - Answers-No
Do TJC, CoP or NCQA standards require criminal background checks? - Answers-No
Does HFAP have any provisions for LIP health? - Answers-no
Does TJC have a requirement for verification of liability coverage? - Answers-None
Does TJC recommend or require that hospitals base evaluations for competence on the
six general areas? - Answers-Recommend
Duties of MEC to be documented in bylaws? - Answers-Acts on behalf of medical staff
between med staff meetings
Mechanism for recommending terminations
If question about ability to perform privileges granted, must request evaluation
Recommend to gov body the structure of med staff
,Recommend to gov body the process for reviewing credentials and delineating
privileges
EMTALA is a section of which ERISA (Employment Retirement Income Security Act),
Internal Revenue Code and Public Health Service Act? - Answers-COBRA
For CoP, surgical privileges must be delineated for all practitioners performing surgery
in accordance with... - Answers-the competencies of each practitioner
For dietary services. how often must the therapeutic diet manual be reviewed? -
Answers-Revision less than five years old.
Must be available for all medical, nursing and food service personnel.
For Medicare deemed facilities, the delegation of credentialing agreement must include
what clause? - Answers-Adhere to Medicare regulations
For non TJC hospital, what are two options for telemedicine credentialing? - Answers-
Verify that all LIPs have appropriate privileges by obtaining copy of privileges
Include in contract that the organization will ensure that services by LIPs are within
scope
For practitioners with federal tort coverage, what is required for liability verification? -
Answers-Copy of Federal Tort letter or
Attestation from provider stating that they hold such coverage
For TJC deemed status hospitals, what are two requirements of the originating site
agreement? - Answers-Distant site is a contractor of services to hospital
Distant site furnishes services in manner permitting orig. site to be compliance with
CoPs
For TJC, does "privileges" refer to duties and prerogatives of each category or the
clinical privileges to provide care? - Answers-Duties and prerogatives
For which accreditation, do the following practitioners need *not* to be credentialed
including:
-exclusively in the inpatient setting caring for organization members only in the hospital
setting
-practice exclusively in free-standing setting for members directed to facility
-pharmacists working for a PBM (pharmacy benefits management) organization for UM
functions
-locum tenens working less than 90 days
-rental network practitioners providing out of area care - Answers-NCQA
For which conditions does HFAP require consultations of patients? - Answers-Critically
ill patients
, Patients who have poor risk for surgery
Patients with difficult or obscure diagnoses
How does HCQIA define recommendations that adversely affect a providers privileges
or med staff appointment? - Answers-Reducing, restricting, suspending, revoking,
denying or failing to renew
How frequently must bylaws be reviewed under HFAP? - Answers-at least every two
years
How frequently under HFAP must the medical staff provide evaluations of
improvements in clinical care? - Answers-Annually
How long does a provider have to request a hearing after being notified of an adverse
recommendation? - Answers-30 days
How many days of suspension of privileges/membership would lead trigger a hearing? -
Answers-Greater than 14 days
How many medical staff members comprise a Bylaws Committee? - Answers-5
At least five active medical staff
How many medical staff members comprise a Credentials Committee? - Answers-5
At least five active medical staff
How many medical staff members must serve on a Medical Records Committee? -
Answers-1
At least one active medical staff
How many medical staff members must serve on a Pharmacy & Therapeutics
Committee? - Answers-5
At least five active medical staff
How many medical staff members must serve on a Utilization Review Committee? -
Answers-1
At least one active medical staff
How many medical staff members must serve on an Infection Control Committee? -
Answers-3
At least three active medical staff
