CMOM Module 5 UPDATED ACTUAL
Exam Questions and CORRECT Answers
Credentialing - CORRECT ANSWER - verifies that a physician meets standards through
the review of license, experience, certification, education, training, malpractice and adverse
clinical occurrences, clinical judgement and character via investigation and observation
Privileging - CORRECT ANSWER - Defines a physician's scope of practice and the
clinical services he or she may provide
Council for Affordable Quality HealthCare (CAQH) - CORRECT ANSWER - not-for-
profit collaborative alliance of health plans and networks which offers a standardized
credentialing process
PECOS (Provider Enrollment, Chain and Ownership System) - CORRECT ANSWER -
Medicare's Internet Based provider enrollment
NCQ (National Committee for Quality Assurance) - CORRECT ANSWER - used to limit
its accreditation to HMOs, but has recently expanded to accredit CVOs, Behavioral Managed
Health Care organizations and Physician Organizations
JCAHO (Joint Commission on Accreditation of Healthcare Organizations - CORRECT
ANSWER - started out as a hospital accreditation org, accredits all types of MCOs through
its health care network accreditation program. They Also have a specific set of standards for
PPOs and Managed Behavioral Health Care Orgs
AAHCC (American Accreditation HealthCare Commission) - CORRECT ANSWER -
only accredits orgs that specialize in carry out utilization reviews. They have recently broadened
their focus to accredit MCOs.
MQC (Medical Quality Commission) - CORRECT ANSWER - The smallest accreditation
group, accredits medical groups and Independent Practice Associations (IPAs)
, Exclusive Managed Indemnity - CORRECT ANSWER - In this type of plan, patient is free
to go to any provider, but plan requires some pre-certification by the payer for inpatient stays and
some outpatient procedures
PHO (Physician Hospital Organization) - CORRECT ANSWER - Tied to a specific
hospital, negotiates with the Managed Care organization (MCO) for integrated or affiliated
services with the hospital
PPO (Preferred Provider Organization) - CORRECT ANSWER - providers are contract
providers and maintained in a network listing provided to beneficiaries. They may self refer and
see any specialist as long as they stay within the network.
Silent PPO - CORRECT ANSWER - A plan that has two ways to access your contracted
discount fee plan.
HMO (Health Maintenance Organization) - CORRECT ANSWER - Contract that typically
uses a captitated form of reimbursement and limits the ability of a patient to see a specialist
without a referral from a PCP as a means to control costs
Group Model (HMO) - CORRECT ANSWER - consists of private practice physicians and
other providers, including hospitals, working under contract with the HMO, accepting discount
FFS or capitation Per Member Per Month (PMPM). Usually a PCP, 'gatekeeper', and patient
cannot see a specialist without referral from the gatekeeper.
Staff Model (HMO) - CORRECT ANSWER - providers are employees of the HMO and
only provide services to hose HMO beneficiaries
Independent Practice Association (IPA) - CORRECT ANSWER - a separate legal entity
that can either organize physicians and contract on their behalf with MCOs to provide services,
or can actually become the HMO and service the covered lines
Exam Questions and CORRECT Answers
Credentialing - CORRECT ANSWER - verifies that a physician meets standards through
the review of license, experience, certification, education, training, malpractice and adverse
clinical occurrences, clinical judgement and character via investigation and observation
Privileging - CORRECT ANSWER - Defines a physician's scope of practice and the
clinical services he or she may provide
Council for Affordable Quality HealthCare (CAQH) - CORRECT ANSWER - not-for-
profit collaborative alliance of health plans and networks which offers a standardized
credentialing process
PECOS (Provider Enrollment, Chain and Ownership System) - CORRECT ANSWER -
Medicare's Internet Based provider enrollment
NCQ (National Committee for Quality Assurance) - CORRECT ANSWER - used to limit
its accreditation to HMOs, but has recently expanded to accredit CVOs, Behavioral Managed
Health Care organizations and Physician Organizations
JCAHO (Joint Commission on Accreditation of Healthcare Organizations - CORRECT
ANSWER - started out as a hospital accreditation org, accredits all types of MCOs through
its health care network accreditation program. They Also have a specific set of standards for
PPOs and Managed Behavioral Health Care Orgs
AAHCC (American Accreditation HealthCare Commission) - CORRECT ANSWER -
only accredits orgs that specialize in carry out utilization reviews. They have recently broadened
their focus to accredit MCOs.
MQC (Medical Quality Commission) - CORRECT ANSWER - The smallest accreditation
group, accredits medical groups and Independent Practice Associations (IPAs)
, Exclusive Managed Indemnity - CORRECT ANSWER - In this type of plan, patient is free
to go to any provider, but plan requires some pre-certification by the payer for inpatient stays and
some outpatient procedures
PHO (Physician Hospital Organization) - CORRECT ANSWER - Tied to a specific
hospital, negotiates with the Managed Care organization (MCO) for integrated or affiliated
services with the hospital
PPO (Preferred Provider Organization) - CORRECT ANSWER - providers are contract
providers and maintained in a network listing provided to beneficiaries. They may self refer and
see any specialist as long as they stay within the network.
Silent PPO - CORRECT ANSWER - A plan that has two ways to access your contracted
discount fee plan.
HMO (Health Maintenance Organization) - CORRECT ANSWER - Contract that typically
uses a captitated form of reimbursement and limits the ability of a patient to see a specialist
without a referral from a PCP as a means to control costs
Group Model (HMO) - CORRECT ANSWER - consists of private practice physicians and
other providers, including hospitals, working under contract with the HMO, accepting discount
FFS or capitation Per Member Per Month (PMPM). Usually a PCP, 'gatekeeper', and patient
cannot see a specialist without referral from the gatekeeper.
Staff Model (HMO) - CORRECT ANSWER - providers are employees of the HMO and
only provide services to hose HMO beneficiaries
Independent Practice Association (IPA) - CORRECT ANSWER - a separate legal entity
that can either organize physicians and contract on their behalf with MCOs to provide services,
or can actually become the HMO and service the covered lines
