CMOM MODULE 5 TEST QUESTIONS AND
ANSWERS
Credentialing - ANSWER A process by which ANSWER verifies that a
physician meets standards through review of license, experience, certification,
education, and training, malpractice and adverse clinical occurrences, clinical
judgement and character by way of investigation and observation
Privileging - ANSWER Establishes a physician's scope of practice and the
clinical services he or she may provide
Council for Affordable Quality HealthCare (CAQH) - ANSWER not-for-profit
collaborative alliance of health plans and networks which offers a standardized
credentialing process
PECOS (Provider Enrollment, Chain and Ownership System) - ANSWER
Medicare's Internet Based provider enrollment
NCQA- National Committee for Quality Assurance - ANSWER used to only
grant its accreditation to HMOs but recently granted their accreditation for
CVOs, Behavioral Managed Health Care organizations, and Physician
Organizations
JCAHO (Joint Commission on Accreditation of Healthcare Organizations -
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) - ANSWER only
accredits orgs that specialize in carry out utilization reviews. They have recently
broadened their focus to accredit MCOs.
MQC (Medical Quality Commission) - ANSWER The smallest accreditation
group, accredits medical groups and Independent Practice Associations (IPAs)
Exclusive Managed Indemnity - 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) - 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)- 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- ANSWER A plan that has two ways to access your contracted
discount fee plan.
HMO -Health Maintenance Organization- ANSWER Contract that often utilizes
a capitated method of reimbursement and limits access to a specialist unless a
referral is made from a PCP in an attempt to control costs.
Group Model (HMO) - 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
ANSWERS
Credentialing - ANSWER A process by which ANSWER verifies that a
physician meets standards through review of license, experience, certification,
education, and training, malpractice and adverse clinical occurrences, clinical
judgement and character by way of investigation and observation
Privileging - ANSWER Establishes a physician's scope of practice and the
clinical services he or she may provide
Council for Affordable Quality HealthCare (CAQH) - ANSWER not-for-profit
collaborative alliance of health plans and networks which offers a standardized
credentialing process
PECOS (Provider Enrollment, Chain and Ownership System) - ANSWER
Medicare's Internet Based provider enrollment
NCQA- National Committee for Quality Assurance - ANSWER used to only
grant its accreditation to HMOs but recently granted their accreditation for
CVOs, Behavioral Managed Health Care organizations, and Physician
Organizations
JCAHO (Joint Commission on Accreditation of Healthcare Organizations -
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) - ANSWER only
accredits orgs that specialize in carry out utilization reviews. They have recently
broadened their focus to accredit MCOs.
MQC (Medical Quality Commission) - ANSWER The smallest accreditation
group, accredits medical groups and Independent Practice Associations (IPAs)
Exclusive Managed Indemnity - 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) - 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)- 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- ANSWER A plan that has two ways to access your contracted
discount fee plan.
HMO -Health Maintenance Organization- ANSWER Contract that often utilizes
a capitated method of reimbursement and limits access to a specialist unless a
referral is made from a PCP in an attempt to control costs.
Group Model (HMO) - 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
