CPMSM Study Guide Exam 2026
Questions and Answers
Where must accreditors submit their standards for approval? - Answer -CMS
When is deemed status given? - Answer -After approval by CMS
What are requirements set by forces outside the organization? - Answer -External
criteria
What factors are defined by the hospital's medical staff and governing body or the
MCO's board? - Answer -Internal criteria
Name possible internal criteria? - Answer -Board certification, an office within
close proximity of facility, alternate coverage, need for a particular specialty,
application fees, minimum amounts for malpractice insurance
Is it an internal or external decision to allow practitioners to practice independently
within the hospital? - Answer -Internal
According to TJC standards, can medical staff membership and privileges be based
solely upon certification, fellowship, or membership in a specialty body? - Answer
-No
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, What is the basis for criteria related to membership and privileging? - Answer -
Quality of healthcare, treatment, and services
Does TJC's interpretation of privileges mean the duties and prerogatives of each
category or the clinical privileges to provide patient care, treatment, and services
related to each category? - Answer -Duties and prerogatives of each category
Does TJC require that an applicant submit a statement that no heath problems exist
that could affect his/her ability to perform the privileges requested? - Answer -Yes
Before granting privileges, the medical staff must evaluate what? - Answer -
Challenges to any licensure;
Voluntary & involuntary relinquishment of any license or registration, termination
of medical staff membership, restrictions of clinical privileges
Does TJC requires the medical staff to evaluate an evidence of an unusual pattern
or an excessive amount of lawsuits prior to granting privileges? - Answer -Yes
According to TJC, organizations that use a CVO must have confidence in what 3
credentialing elements? - Answer -Completeness
Accuracy
Timeliness
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
Questions and Answers
Where must accreditors submit their standards for approval? - Answer -CMS
When is deemed status given? - Answer -After approval by CMS
What are requirements set by forces outside the organization? - Answer -External
criteria
What factors are defined by the hospital's medical staff and governing body or the
MCO's board? - Answer -Internal criteria
Name possible internal criteria? - Answer -Board certification, an office within
close proximity of facility, alternate coverage, need for a particular specialty,
application fees, minimum amounts for malpractice insurance
Is it an internal or external decision to allow practitioners to practice independently
within the hospital? - Answer -Internal
According to TJC standards, can medical staff membership and privileges be based
solely upon certification, fellowship, or membership in a specialty body? - Answer
-No
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
, What is the basis for criteria related to membership and privileging? - Answer -
Quality of healthcare, treatment, and services
Does TJC's interpretation of privileges mean the duties and prerogatives of each
category or the clinical privileges to provide patient care, treatment, and services
related to each category? - Answer -Duties and prerogatives of each category
Does TJC require that an applicant submit a statement that no heath problems exist
that could affect his/her ability to perform the privileges requested? - Answer -Yes
Before granting privileges, the medical staff must evaluate what? - Answer -
Challenges to any licensure;
Voluntary & involuntary relinquishment of any license or registration, termination
of medical staff membership, restrictions of clinical privileges
Does TJC requires the medical staff to evaluate an evidence of an unusual pattern
or an excessive amount of lawsuits prior to granting privileges? - Answer -Yes
According to TJC, organizations that use a CVO must have confidence in what 3
credentialing elements? - Answer -Completeness
Accuracy
Timeliness
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
