CPCS TEST PAPER ALL TIPS QUESTIONS AND ANSWERS
SURE A+
✔✔Peer recommendation - when used TJC - ✔✔Initial granting of privileges and
appointment
Termination from medical staff or revocation/revision of privileges
If insufficient practitioner data when renewing privileges
✔✔Peer recommendation includes - TJC - ✔✔Evaluation of applicant's
1) medical/clinical knowledge,
2) technical and clinical skills,
3) clinical judgment
4) communication skills
5) interpersonal skills
6) professionalism
✔✔Peer recommendation sources - TJC - ✔✔1) Organization performance
improvement committee (majority are applicant's peers)
2) Reference letter, written documentation, or documented phone conversation - to be
peer must be in same professional discipline and have personal knowledge of applicant
3) department or major clinical service chairperson who is a peer
4) the MEC (medical staff executive committee)
✔✔Peer recommendation - when used HFAP - ✔✔initial appointment not at
reapplication
✔✔Peer recommendation - who provides - HFAP - ✔✔at least one peer with same
credential as applicant
if not available, then practitioner in same practice area who can speak to professional
competence and ethical standards
✔✔Peer recommendation - how documented - HFAP - ✔✔statement regarding
physician's physical and mental health in relation to privileges requested
✔✔Peer recommendation - how many and how often - DNV - ✔✔2 peer
recommendations on initial appointment
✔✔Peer recommendation required when - AAAHC - ✔✔initial and reappointment
✔✔State licensing may replace what verification - NCQA - ✔✔education, residency
training, and board certification
as long as state licensing verification process reviwed annually
✔✔What date is used for written verification received by organization? NCQA -
✔✔Official document/report date (not date received)
, used to measure timeliness
✔✔If electronic information does not generate a date, what date does NCQA use? -
✔✔Date documented in credentialing file by staff person who verified credentials
✔✔NCQA timeframe for licensure, malpractice history, sanctions, and board
certification - ✔✔180 days of application approval MCO
120 days CVO
✔✔Process for LIPs, APRNs, and PAs to be credentialied - TJC - ✔✔through medical
staff process NOT equivalent
✔✔Peer references may only be provided by those listed on application w/consent &
release - T/F? - ✔✔False. Application should release organiztion to obtain info from
sources other than those listed on application
✔✔LIPs who are hospital employees - credentialed and privileged under Medical Staff
standards - TJC? - ✔✔Yes
✔✔Privileges to non-physicians - HFAP - ✔✔must be in accordance with State law,
regulations, scope of practice
✔✔Privileges - who? AAAHC - ✔✔Physicians & dentists
Board determines if AHPs privileged and which on staff
✔✔Practitioners that are credentialed - NCQA - ✔✔Practitioners licensed who can
practice independently
Practitioners with independent relationship to organization
Practiitioners who provide care under organization's medical benefits
includes group practices, facilities, rental networks, telemed
✔✔Practitioners that are credentialed - URAC - ✔✔All practitioners listed in directory
(physician and other practitioners)
Hospitalists and facility employees not credentialed
✔✔Privileges requirements - TJC - ✔✔PSV for current licensure or board cert
PSV of relevant training
Evidence of physical ability to perform privilege
Data from professional practice
Recommendations from peers/faculty
renewal - review of performance in hospital
Attestation that no health problems
Query NPDB
SURE A+
✔✔Peer recommendation - when used TJC - ✔✔Initial granting of privileges and
appointment
Termination from medical staff or revocation/revision of privileges
If insufficient practitioner data when renewing privileges
✔✔Peer recommendation includes - TJC - ✔✔Evaluation of applicant's
1) medical/clinical knowledge,
2) technical and clinical skills,
3) clinical judgment
4) communication skills
5) interpersonal skills
6) professionalism
✔✔Peer recommendation sources - TJC - ✔✔1) Organization performance
improvement committee (majority are applicant's peers)
2) Reference letter, written documentation, or documented phone conversation - to be
peer must be in same professional discipline and have personal knowledge of applicant
3) department or major clinical service chairperson who is a peer
4) the MEC (medical staff executive committee)
✔✔Peer recommendation - when used HFAP - ✔✔initial appointment not at
reapplication
✔✔Peer recommendation - who provides - HFAP - ✔✔at least one peer with same
credential as applicant
if not available, then practitioner in same practice area who can speak to professional
competence and ethical standards
✔✔Peer recommendation - how documented - HFAP - ✔✔statement regarding
physician's physical and mental health in relation to privileges requested
✔✔Peer recommendation - how many and how often - DNV - ✔✔2 peer
recommendations on initial appointment
✔✔Peer recommendation required when - AAAHC - ✔✔initial and reappointment
✔✔State licensing may replace what verification - NCQA - ✔✔education, residency
training, and board certification
as long as state licensing verification process reviwed annually
✔✔What date is used for written verification received by organization? NCQA -
✔✔Official document/report date (not date received)
, used to measure timeliness
✔✔If electronic information does not generate a date, what date does NCQA use? -
✔✔Date documented in credentialing file by staff person who verified credentials
✔✔NCQA timeframe for licensure, malpractice history, sanctions, and board
certification - ✔✔180 days of application approval MCO
120 days CVO
✔✔Process for LIPs, APRNs, and PAs to be credentialied - TJC - ✔✔through medical
staff process NOT equivalent
✔✔Peer references may only be provided by those listed on application w/consent &
release - T/F? - ✔✔False. Application should release organiztion to obtain info from
sources other than those listed on application
✔✔LIPs who are hospital employees - credentialed and privileged under Medical Staff
standards - TJC? - ✔✔Yes
✔✔Privileges to non-physicians - HFAP - ✔✔must be in accordance with State law,
regulations, scope of practice
✔✔Privileges - who? AAAHC - ✔✔Physicians & dentists
Board determines if AHPs privileged and which on staff
✔✔Practitioners that are credentialed - NCQA - ✔✔Practitioners licensed who can
practice independently
Practitioners with independent relationship to organization
Practiitioners who provide care under organization's medical benefits
includes group practices, facilities, rental networks, telemed
✔✔Practitioners that are credentialed - URAC - ✔✔All practitioners listed in directory
(physician and other practitioners)
Hospitalists and facility employees not credentialed
✔✔Privileges requirements - TJC - ✔✔PSV for current licensure or board cert
PSV of relevant training
Evidence of physical ability to perform privilege
Data from professional practice
Recommendations from peers/faculty
renewal - review of performance in hospital
Attestation that no health problems
Query NPDB
