CPMSM - Study Guide Material With
Verified Answers
What are four models of HMOs? - ANSWER -Staff Model
Group Model
Network Model
Independent Practice Association (IPA)
What are the four types of committees? - ANSWER -Standing
Ad hoc
Task force
Continuous quality improvement team
How many medical staff members comprise a Bylaws Committee? - ANSWER -5
At least five active medical staff
How many medical staff members comprise a Credentials Committee? - ANSWER -5
At least five active medical staff
How many medical staff members must serve on an Infection Control Committee? -
ANSWER -3
At least three active medical staff
How many medical staff members must serve on a Medical Records Committee? -
ANSWER -1
At least one active medical staff
How often should the Medical Records committee meet? - ANSWER -At least quarterly
How many medical staff members must serve on a Pharmacy & Therapeutics
Committee? - ANSWER -5
At least five active medical staff
How often should the Pharmacy & Therapeutics committee meet? - ANSWER -At least
quarterly
How many medical staff members must serve on a Utilization Review Committee? -
ANSWER -1
,At least one active medical staff
How often should the Utilization Review Committee meet? - ANSWER -Every other
month
What is the process of obtaining, verifying, and assessing the qualifications of a health
care practitioner who seeks to provide patient care services in or for a hospital? -
ANSWER -Credentialing
What are the three reasons for credentialing? - ANSWER -Patient Safety
Risk Management
Required by agencies
Which three accreditors have been granted "deemed status"? - ANSWER -TJC, HFAP,
DNV
Which two organizations offer accreditation for managed care organizations? -
ANSWER -NCQA, URAC
Who is the main accreditor for ambulatory care facilities? - ANSWER -AAAHC
Physicians who are employees of a facility as hospitalists and who are not listed in the
provider directory are not included in the scope of the credentialing standards with this
accreditation? - ANSWER -URAC
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 - ANSWER -NCQA
What are Medicare CoP's minimum criteria for appointment to the medical staff/granting
of medical staff privileges? - ANSWER -CCJET
character
competence
judgement
experience
training
CMS regulations require that medical staff bylaws include what information pertaining to
each category of the medical staff? - ANSWER -duties and privileges
, Do providers with refer and follow status have admitting privileges/ordering privileges
within the hospital? - ANSWER -No
For TJC, does "privileges" refer to duties and prerogatives of each category or the
clinical privileges to provide care? - ANSWER -Duties and prerogatives
Which accreditor requires an applicant to submit a statement that no health problems
exist which could affect his or her ability to provide care? - ANSWER -TJC
Which accreditor has *no* specific requirements for professional practice questions on
the application or reapp? - ANSWER -DNV
For Medicare deemed facilities, the delegation of credentialing agreement must include
what clause? - ANSWER -Adhere to Medicare regulations
How often must the delegate organization provide a report to Credentials for a URAC
facility? - ANSWER -Annually
What is the NCQA requirement for monitoring member complaints about providers? -
ANSWER -Continually monitoring member complaints for all practitioner sites
Performing a site visit within 60 days if a threshold was met
What is the only NCQA-required reporting for delegated credentialing? - ANSWER -The
names or files of practitioners or providers processed by the delegate
What is the credentialing timeframe for URAC? - ANSWER -6 months
No credentialing application is submitted for initial review if it is signed and dated more
than 180 days prior to credentialing committee review or if it contains primary or
secondary source verification information collected more than six months prior to
review.
What are the two requirements for verification at reappointment for DNV? - ANSWER -
Licensure
Current Competence
What is verification of a practitioner's credentials based upon evidence obtains by
means other than direct contact with the issuing source of the credential? (e.g. copies of
licenses/certifications or database queries) - ANSWER -Secondary Source
What year was HIPAA established? - ANSWER -1996
Which two entities can report to HIPDB? - ANSWER -Federal/state government
agencies
Health Plans
Verified Answers
What are four models of HMOs? - ANSWER -Staff Model
Group Model
Network Model
Independent Practice Association (IPA)
What are the four types of committees? - ANSWER -Standing
Ad hoc
Task force
Continuous quality improvement team
How many medical staff members comprise a Bylaws Committee? - ANSWER -5
At least five active medical staff
How many medical staff members comprise a Credentials Committee? - ANSWER -5
At least five active medical staff
How many medical staff members must serve on an Infection Control Committee? -
ANSWER -3
At least three active medical staff
How many medical staff members must serve on a Medical Records Committee? -
ANSWER -1
At least one active medical staff
How often should the Medical Records committee meet? - ANSWER -At least quarterly
How many medical staff members must serve on a Pharmacy & Therapeutics
Committee? - ANSWER -5
At least five active medical staff
How often should the Pharmacy & Therapeutics committee meet? - ANSWER -At least
quarterly
How many medical staff members must serve on a Utilization Review Committee? -
ANSWER -1
,At least one active medical staff
How often should the Utilization Review Committee meet? - ANSWER -Every other
month
What is the process of obtaining, verifying, and assessing the qualifications of a health
care practitioner who seeks to provide patient care services in or for a hospital? -
ANSWER -Credentialing
What are the three reasons for credentialing? - ANSWER -Patient Safety
Risk Management
Required by agencies
Which three accreditors have been granted "deemed status"? - ANSWER -TJC, HFAP,
DNV
Which two organizations offer accreditation for managed care organizations? -
ANSWER -NCQA, URAC
Who is the main accreditor for ambulatory care facilities? - ANSWER -AAAHC
Physicians who are employees of a facility as hospitalists and who are not listed in the
provider directory are not included in the scope of the credentialing standards with this
accreditation? - ANSWER -URAC
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 - ANSWER -NCQA
What are Medicare CoP's minimum criteria for appointment to the medical staff/granting
of medical staff privileges? - ANSWER -CCJET
character
competence
judgement
experience
training
CMS regulations require that medical staff bylaws include what information pertaining to
each category of the medical staff? - ANSWER -duties and privileges
, Do providers with refer and follow status have admitting privileges/ordering privileges
within the hospital? - ANSWER -No
For TJC, does "privileges" refer to duties and prerogatives of each category or the
clinical privileges to provide care? - ANSWER -Duties and prerogatives
Which accreditor requires an applicant to submit a statement that no health problems
exist which could affect his or her ability to provide care? - ANSWER -TJC
Which accreditor has *no* specific requirements for professional practice questions on
the application or reapp? - ANSWER -DNV
For Medicare deemed facilities, the delegation of credentialing agreement must include
what clause? - ANSWER -Adhere to Medicare regulations
How often must the delegate organization provide a report to Credentials for a URAC
facility? - ANSWER -Annually
What is the NCQA requirement for monitoring member complaints about providers? -
ANSWER -Continually monitoring member complaints for all practitioner sites
Performing a site visit within 60 days if a threshold was met
What is the only NCQA-required reporting for delegated credentialing? - ANSWER -The
names or files of practitioners or providers processed by the delegate
What is the credentialing timeframe for URAC? - ANSWER -6 months
No credentialing application is submitted for initial review if it is signed and dated more
than 180 days prior to credentialing committee review or if it contains primary or
secondary source verification information collected more than six months prior to
review.
What are the two requirements for verification at reappointment for DNV? - ANSWER -
Licensure
Current Competence
What is verification of a practitioner's credentials based upon evidence obtains by
means other than direct contact with the issuing source of the credential? (e.g. copies of
licenses/certifications or database queries) - ANSWER -Secondary Source
What year was HIPAA established? - ANSWER -1996
Which two entities can report to HIPDB? - ANSWER -Federal/state government
agencies
Health Plans
