CPMSM COMPREHENSIVE ANSWERS AND
QUESTIONS SET A+
✔✔The 3 committees required by HFAP Standards - ✔✔1. Medical Executive
Committee
2. Utilization of Osteopathic Methods and Concepts Committee (if there are 10 or more
DO's on the Medical Staff.
3. Utilization Review Committee
✔✔Peer References - ✔✔Should be obtained from practitioners in the same
professional discipline as the applicant.
✔✔Patrick V. Burgett - ✔✔Illustrates the potential for antitrust liability arising our of peer
review activities not performed in good faith.
✔✔Due Process - ✔✔If a medical staff member has privileges and / or medical staff
appointment revoked he/she must be provided:
✔✔Access Policy - ✔✔Access to Credentials files should be fully described in an
access policy.
✔✔Governing Body or Board - ✔✔Is the final approval of clinical privileges.
Credentials Committee > Med Exec
Med Exec > Board/Governing Body
✔✔According to TJC Standards - ✔✔Initial appointments to the medical staff are made
for a period of time not to exceed two years.
✔✔TJC requires the following items to be PSV - ✔✔Licensure, Training, experience,
and competence
, ✔✔Federation of State Medical Boards - ✔✔According to NCQA standards, is an
acceptable source for primary source verification of Medicare and Medicaid Sanction
activity.
✔✔The American Board of Medical Specialties - ✔✔According to The Joint Commission
standards, the ABMS is considered a designated equivalent source for verification of
board certification.
✔✔American Medical Association Mater File - ✔✔Is recognized by TJC and NCQA to
provider primary source verification of medical school graduation and residency training
for U.S. graduates.
✔✔NCQA attestation statement must include - ✔✔affirmation that the application is
correct and complete.
✔✔According to TJC standards the Medical Staff Bylaws - ✔✔Should define the
structure of the Medical Staff
✔✔According to TJC standards, professional criteria for granting of clinical privileges
must include at least - ✔✔Relevant training or experience, ability to perform privileges
requested, current licensure, and competence
✔✔TJC Standards require the Medical Staff Bylaws to - ✔✔include a mechanism for
selection and removal of officers
✔✔According to NCQA standards an appropriate verification source for verification of
board certification - ✔✔state licensing agency, if state agency conducts primary
verification of board status.
✔✔TJC requires for Re-Appointment to the medical staff - ✔✔Primary source
verification of malpractice suits
✔✔URAC's health network standards state - ✔✔each applicant within the scope of the
credentialing program submits an application that includes at least
-State licensure information, including current license(s) and history of licensure in all
jurisdictions.
✔✔According to AAAHC current Licensure - ✔✔must be monitored on an ongoing basis
✔✔According to TJC a Nurse Practitioner - ✔✔functioning independently and providing
a medical level of care must be granted delineated clinical privileges
✔✔Education Commission of Foreign Medical Graduates - ✔✔Acceptable source for
verification for medical education of an international graduate.
QUESTIONS SET A+
✔✔The 3 committees required by HFAP Standards - ✔✔1. Medical Executive
Committee
2. Utilization of Osteopathic Methods and Concepts Committee (if there are 10 or more
DO's on the Medical Staff.
3. Utilization Review Committee
✔✔Peer References - ✔✔Should be obtained from practitioners in the same
professional discipline as the applicant.
✔✔Patrick V. Burgett - ✔✔Illustrates the potential for antitrust liability arising our of peer
review activities not performed in good faith.
✔✔Due Process - ✔✔If a medical staff member has privileges and / or medical staff
appointment revoked he/she must be provided:
✔✔Access Policy - ✔✔Access to Credentials files should be fully described in an
access policy.
✔✔Governing Body or Board - ✔✔Is the final approval of clinical privileges.
Credentials Committee > Med Exec
Med Exec > Board/Governing Body
✔✔According to TJC Standards - ✔✔Initial appointments to the medical staff are made
for a period of time not to exceed two years.
✔✔TJC requires the following items to be PSV - ✔✔Licensure, Training, experience,
and competence
, ✔✔Federation of State Medical Boards - ✔✔According to NCQA standards, is an
acceptable source for primary source verification of Medicare and Medicaid Sanction
activity.
✔✔The American Board of Medical Specialties - ✔✔According to The Joint Commission
standards, the ABMS is considered a designated equivalent source for verification of
board certification.
✔✔American Medical Association Mater File - ✔✔Is recognized by TJC and NCQA to
provider primary source verification of medical school graduation and residency training
for U.S. graduates.
✔✔NCQA attestation statement must include - ✔✔affirmation that the application is
correct and complete.
✔✔According to TJC standards the Medical Staff Bylaws - ✔✔Should define the
structure of the Medical Staff
✔✔According to TJC standards, professional criteria for granting of clinical privileges
must include at least - ✔✔Relevant training or experience, ability to perform privileges
requested, current licensure, and competence
✔✔TJC Standards require the Medical Staff Bylaws to - ✔✔include a mechanism for
selection and removal of officers
✔✔According to NCQA standards an appropriate verification source for verification of
board certification - ✔✔state licensing agency, if state agency conducts primary
verification of board status.
✔✔TJC requires for Re-Appointment to the medical staff - ✔✔Primary source
verification of malpractice suits
✔✔URAC's health network standards state - ✔✔each applicant within the scope of the
credentialing program submits an application that includes at least
-State licensure information, including current license(s) and history of licensure in all
jurisdictions.
✔✔According to AAAHC current Licensure - ✔✔must be monitored on an ongoing basis
✔✔According to TJC a Nurse Practitioner - ✔✔functioning independently and providing
a medical level of care must be granted delineated clinical privileges
✔✔Education Commission of Foreign Medical Graduates - ✔✔Acceptable source for
verification for medical education of an international graduate.
