CPCS Exam 2023-2024 Questions and Answers (Graded A)
MCO acronym for - ANSWER-Managed Care Organization - main accreditors: NCQA, URAC
NAMSS acronym for - ANSWER-National Association of Medical Staff Services
CPCS acronym for - ANSWER-Certified Provider Credentialing Specialist
CVO acronym for - ANSWER-Credential Verifications Organization
HEDIS acronym for - ANSWER-Healthcare Effectiveness Data Information Set
CAHPS acronym for - ANSWER-Consumer Assessment of Healthcare Providers & Systems
Structure of a CVO - ANSWER-Director - Contract Sales - Credentialing Staff - Human Resources
Structure of a MCO - ANSWER-Director - Contracts Management - Client Services - Financial Management - Network Admin
Definition of CVO per Industry terms - ANSWER-Commercial third party payers, healthcare networks, and health plans
2 types of CVO - ANSWER-Organization Specific
Independent
Medicare CoPs (CCJET) - ANSWER-Character
Competence
Judgement
Experience Training
Definition of Compliance - ANSWER-Comply with accredited atom and regulatory standards (i.e. Audits, Obtain & evaluate sanctions, etc)
Reasons for Credentialing - ANSWER-Patient safety
Risk management
Accrediting & Regulatory Agencies Definition of CoP's - ANSWER-Medicare Conditions of Participation: Code of Federal Regulations intended to protect patient health & safety
TJC - definition of Credentialing - ANSWER-Process of obtaining, verifying & assessing the qualifications of a healthcare practitioner who seeks to provide patient care services for a hospital
NCQA definition of Credentialing - ANSWER-Process by which an organization reviews and evaluates qualifications of a LIP to provide services to its members
Reasons to get accredited - ANSWER-Quality of care
Accrediting bodies
Deemed Status - participation in Medicare/Medicaid
Liability insurance premiums
Managed care contracts Unions may require for healthcare to employees
Basics of Bylaws - ANSWER-Unique to each hospital
Guidelines serve to ensure compliance
Regular review required
Bylaw changes not effective until board approved
State requirements may influence
CMS Rule for Governing Body - ANSWER-Governing Body has authority to approve/disapprove bylaws suggested by med staff and revisions before approving
Rules & Regs - ANSWER-Detail what med staff appointees may or may not do
Med staff may delegate authority to change rules/regs to MEC
Hospital Credentialing Organizations - ANSWER-TJC, DNV, HFAP
Policies & Procedures - ANSWER-Describe course or conduct/action/management of a matter or circumstance. Often address internal matters
MCO Credentialing Organizations - ANSWER-NCQA, URAC
NCQA - Time limit for verification of Board Certification - ANSWER-180 days, 120 for CVO
URAC - Time limit for verification of Board Certification - ANSWER-6 months
AAAHC - Time limit for verification of Board Certification - ANSWER-Rule states: Verify on application and on an ongoing basis Definition of Licensure - ANSWER-A license is the authority a government agency grants an individual to practice a profession
Definition of State Licensure - ANSWER-Regulation of medical and other professional practice is a state function. State exercises the regulation f medical practice through licensing laws, which include both regulations of health work force and institutions
Medicare CoPs - License Verification - ANSWER-Hospital must assure that staff are licensed or meet other standards required by state/local law. All staff required by state to be licensed must possess a current license. Must ensure staff comply with state laws (vary from state to state)
NCQA Ceedentials? - ANSWER-LIP's (physician & non-physician)
Provide care to organization's members
Outside hospital setting
Free-standing ambulatory facilities Hospital based who see members as result of independent relationship with org.
Rental network practitioners
Telemedicine with independent relationship
NCQA does not credential? - ANSWER-Providers exclusive to inpatient setting
Providers exclusive to free-standing facility with care as result of member being directed
to facility
Locums unless greater than 90 days
Board certified consultants
Rental network provider out-of-area care
URAC acronym for - ANSWER-Utilization Review Accreditation Commission
AAAHC acronym for - ANSWER-Accreditation Association for Ambulatory Healthcare
Who does AAAHC credential? - ANSWER-Do not specify which providers need to be credentialed Governing body defines criteria for initial and reappointment of physicians and dentists
AAAHC Credentialing Criteria - ANSWER-Must have process that describes minimum requirements, process to review/assess individual qualifications such as
Education, experience, cert, lic, competency
TJC - Staff Status Categories:
Interprets the word "Privileges" to mean - ANSWER-Duties and prerogatives of each category, and not the clinical privileges to provide patient care, treatment, and services related to each category
MCO acronym for - ANSWER-Managed Care Organization - main accreditors: NCQA, URAC
NAMSS acronym for - ANSWER-National Association of Medical Staff Services
CPCS acronym for - ANSWER-Certified Provider Credentialing Specialist
CVO acronym for - ANSWER-Credential Verifications Organization
HEDIS acronym for - ANSWER-Healthcare Effectiveness Data Information Set
CAHPS acronym for - ANSWER-Consumer Assessment of Healthcare Providers & Systems
Structure of a CVO - ANSWER-Director - Contract Sales - Credentialing Staff - Human Resources
Structure of a MCO - ANSWER-Director - Contracts Management - Client Services - Financial Management - Network Admin
Definition of CVO per Industry terms - ANSWER-Commercial third party payers, healthcare networks, and health plans
2 types of CVO - ANSWER-Organization Specific
Independent
Medicare CoPs (CCJET) - ANSWER-Character
Competence
Judgement
Experience Training
Definition of Compliance - ANSWER-Comply with accredited atom and regulatory standards (i.e. Audits, Obtain & evaluate sanctions, etc)
Reasons for Credentialing - ANSWER-Patient safety
Risk management
Accrediting & Regulatory Agencies Definition of CoP's - ANSWER-Medicare Conditions of Participation: Code of Federal Regulations intended to protect patient health & safety
TJC - definition of Credentialing - ANSWER-Process of obtaining, verifying & assessing the qualifications of a healthcare practitioner who seeks to provide patient care services for a hospital
NCQA definition of Credentialing - ANSWER-Process by which an organization reviews and evaluates qualifications of a LIP to provide services to its members
Reasons to get accredited - ANSWER-Quality of care
Accrediting bodies
Deemed Status - participation in Medicare/Medicaid
Liability insurance premiums
Managed care contracts Unions may require for healthcare to employees
Basics of Bylaws - ANSWER-Unique to each hospital
Guidelines serve to ensure compliance
Regular review required
Bylaw changes not effective until board approved
State requirements may influence
CMS Rule for Governing Body - ANSWER-Governing Body has authority to approve/disapprove bylaws suggested by med staff and revisions before approving
Rules & Regs - ANSWER-Detail what med staff appointees may or may not do
Med staff may delegate authority to change rules/regs to MEC
Hospital Credentialing Organizations - ANSWER-TJC, DNV, HFAP
Policies & Procedures - ANSWER-Describe course or conduct/action/management of a matter or circumstance. Often address internal matters
MCO Credentialing Organizations - ANSWER-NCQA, URAC
NCQA - Time limit for verification of Board Certification - ANSWER-180 days, 120 for CVO
URAC - Time limit for verification of Board Certification - ANSWER-6 months
AAAHC - Time limit for verification of Board Certification - ANSWER-Rule states: Verify on application and on an ongoing basis Definition of Licensure - ANSWER-A license is the authority a government agency grants an individual to practice a profession
Definition of State Licensure - ANSWER-Regulation of medical and other professional practice is a state function. State exercises the regulation f medical practice through licensing laws, which include both regulations of health work force and institutions
Medicare CoPs - License Verification - ANSWER-Hospital must assure that staff are licensed or meet other standards required by state/local law. All staff required by state to be licensed must possess a current license. Must ensure staff comply with state laws (vary from state to state)
NCQA Ceedentials? - ANSWER-LIP's (physician & non-physician)
Provide care to organization's members
Outside hospital setting
Free-standing ambulatory facilities Hospital based who see members as result of independent relationship with org.
Rental network practitioners
Telemedicine with independent relationship
NCQA does not credential? - ANSWER-Providers exclusive to inpatient setting
Providers exclusive to free-standing facility with care as result of member being directed
to facility
Locums unless greater than 90 days
Board certified consultants
Rental network provider out-of-area care
URAC acronym for - ANSWER-Utilization Review Accreditation Commission
AAAHC acronym for - ANSWER-Accreditation Association for Ambulatory Healthcare
Who does AAAHC credential? - ANSWER-Do not specify which providers need to be credentialed Governing body defines criteria for initial and reappointment of physicians and dentists
AAAHC Credentialing Criteria - ANSWER-Must have process that describes minimum requirements, process to review/assess individual qualifications such as
Education, experience, cert, lic, competency
TJC - Staff Status Categories:
Interprets the word "Privileges" to mean - ANSWER-Duties and prerogatives of each category, and not the clinical privileges to provide patient care, treatment, and services related to each category
