CPCS - Credentialing and Privileging Questions and Answers Rated A+

CPCS - Credentialing and Privileging Questions and Answers Rated A+ TJC Phone PSV What accreditation can use phone for PSV for all information including: licensure, education, training, experience, competence, and peer references LIP any individual permitted by law and by the hospital to provide patient care services w/o direction or supervision, LIP any individual permitted by law and by the hospital to provide patient care services w/o direction or supervision, TJC - DNV - HFAP Accreditation bodies for hospitals TJC - DNV - HFAP Accreditation bodies for hospitals NCQA - URAC Accreditation bodies for Managed Care Organizations (MCO) NCQA who to credential credentialing is required for all licensed practitioners (physicians and non physicians) NCQA - URAC Accreditation bodies for Managed Care Organizations (MCO) NCQA not credentialed inpatient setting for organizational member only - pharmacy benefits management - locum tenens unless over 90 days - NCQA What accreditation requires credentialing for all licensed practitioners (physicians and non physicians) URAC who to credential All participating providers as well as facilities that provide covered health care services to consumers. All practitioners listed in the directory must be credentialed NCQA What accreditation does not require credentialing in these settings? Inpatient setting for organizational member only - pharmacy benefits management - locum tenens unless over 90 days - URAC Directory Criteria Quality of Care, Service, and business need of organization URAC What accreditation requires all participating providers as well as facilities that provide covered health care services to consumers. All practitioners listed in the directory must be credentialed URAC Directory Criteria What accreditation required the following criteria? Quality of Care, Service, and business need of organization URAC - not credentialed Physicians who are employees of a facility as hospitalists and who are not listed in the directory. URAC What accreditation does not require you to credential: Physicians who are employees of a facility as hospitalists and who are not listed in the directory. Ambulatory Care Facility (AAAHC) the governing body defines criteria for initial and reappointment of physicians and dentist. They do not specify which providers need to be credentialed. Definition of Criteria requirements for appointment to the medical staff or provider panel Ambulatory Care Facility (AAAHC) What accreditation requires the governing body to define criteria for initial and reappointment of physicians and dentist. They do not specify which providers need to be credentialed. core criteria education, training, current competence, health status, and licensure Criteria This is the definition of: requirements for appointment to the medical staff or provider panel external criteria requirements set by forces outside the organization - TJC, NCQA, state and federal regulations, COP's. State licensing laws describe who can be credentialed. core criteria What is the definition of: education, training, current competence, health status, and licensure internal criteria factors defined by the hospital's medical staff and governing board External Criteria Qualification for Membership - requirements set by forces outside the organization - TJC, NCQA, state and federal regulations, COP's. State licensing laws describe who can be credentialed. internal criteria Qualifications for Membership - factors defined by the hospital's medical staff and governing board or MCO board. Criteria may included board certification, geographic distance, alternate coverage. Patient Safety, Risk Management Concerns, and Required by regulatory agencies. What are the three reasons for Credentialing Protect patient health and safety and to ensure quality of care for hospitalized patients. What is the reason for CoP's? Accreditation assists organizations in monitoring and improving quality of care. Why get accredited? 1864 Social Security Act Allows Medicare to enter into an agreement with any state to survey hospitals accredited TJC Definition of Credentialing the process of obtaining verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care series in or for a hospital. NCQA Definition of Credentialing a process by which an organization review and evaluates qualifications of licensed independent practitioners to provide services to it's members. AAAHC What accreditation is for ambulatory care facilities? Rules & Regulations Include detailed requirements for specific clinical processes and may include rules of each clinical department. MEC Who may the Medical staff delegate authority for changing the Rules & Regulations? Managed Care Organizations Who uses Policy and Procedures? Policy and Procedures describe the course of conduct or action