CPCS Exam 2025
MCO acronym for - ANS -Managed Care Organization - main accreditors: NCQA, URAC
NAMSS acronym for - ANS -National Association of Medical Staff Services
CPCS acronym for - ANS -Certified Provider Credentialing Specialist
CVO acronym for - ANS -Credential Verifications Organization
HEDIS acronym for - ANS -Healthcare Effectiveness Data Information Set
CAHPS acronym for - ANS -Consumer Assessment of Healthcare Providers & Systems
Structure of a CVO - ANS -Director - Contract Sales - Credentialing Staff - Human Resources
Structure of a MCO - ANS -Director - Contracts Management - Client Services
- Financial Management - Network Admin
Definition of CVO per Industry terms - ANS -Commercial third party payers, healthcare
networks, and health plans
2 types of CVO - ANS -Organization Specific
Independent
Medicare CoPs (CCJET) - ANS -Character
Competence
Judgement
Experience
Training
Definition of Compliance - ANS -Comply with accredited atom and regulatory standards (i.e.
Audits, Obtain & evaluate sanctions, etc)
Reasons for Credentialing - ANS -Patient safety
Risk management
Accrediting & Regulatory Agencies
Definition of CoP's - ANS -Medicare Conditions of Participation: Code of Federal Regulations
intended to protect patient health & safety
,TJC - definition of Credentialing - ANS -Process of obtaining, verifying & assessing the
qualifications of a healthcare practitioner who seeks to provide patient care services for a
hospital
NCQA definition of Credentialing - ANS -Process by which an organization reviews and
evaluates qualifications of a LIP to provide services to its members
Reasons to get accredited - ANS -Quality of care
Accrediting bodies
Deemed Status - participation in Medicare/Medicaid
Liability insurance premiums
Managed care contracts
Unions may require for healthcare to employees
Basics of Bylaws - ANS -Unique to each hospital
Guidelines serve to ensure compliance
Regular review required
Bylaw changes not effective until board approved
State requirements may influence
CMS Rule for Governing Body - ANS -Governing Body has authority to approve/disapprove
bylaws suggested by med staff and revisions before approving
Rules & Regs - ANS -Detail what med staff appointees may or may not do
Med staff may delegate authority to change rules/regs to MEC
Hospital Credentialing Organizations - ANS -TJC, DNV, HFAP
Policies & Procedures - ANS -Describe course or conduct/action/management of a matter or
circumstance.
Often address internal matters
MCO Credentialing Organizations - ANS -NCQA, URAC
NCQA - Time limit for verification of Board Certification - ANS -180 days, 120 for CVO
URAC - Time limit for verification of Board Certification - ANS -6 months
AAAHC - Time limit for verification of Board Certification - ANS -Rule states: Verify on
application and on an ongoing basis
Definition of Licensure - ANS -A license is the authority a government agency grants an
individual to practice a profession
, Definition of State Licensure - ANS -Regulation of medical and other professional practice is a
state function. State exercises the regulation f medical practice through licensing laws, which
include both regulations of health work force and institutions
Medicare CoPs - License Verification - ANS -Hospital must assure that staff are licensed or
meet other standards required by state/local law. All staff required by state to be licensed must
possess a current license. Must ensure staff comply with state laws (vary from state to state)
NCQA Ceedentials? - ANS -LIP's (physician & non-physician)
Provide care to organization's members
Outside hospital setting
Free-standing ambulatory facilities
Hospital based who see members as result of independent relationship with org.
Rental network practitioners
Telemedicine with independent relationship
NCQA does not credential? - ANS -Providers exclusive to inpatient setting
Providers exclusive to free-standing facility with care as result of member being directed to
facility
Locums unless greater than 90 days
Board certified consultants
Rental network provider out-of-area care
URAC acronym for - ANS -Utilization Review Accreditation Commission
AAAHC acronym for - ANS -Accreditation Association for Ambulatory Healthcare
Who does AAAHC credential? - ANS -Do not specify which providers need to be credentialed
Governing body defines criteria for initial and reappointment of physicians and dentists
AAAHC Credentialing Criteria - ANS -Must have process that describes minimum requirements,
process to review/assess individual qualifications such as
Education, experience, cert, lic, competency
TJC - Staff Status Categories:
Interprets the word "Privileges" to mean - ANS -Duties and prerogatives of each category, and
not the clinical privileges to provide patient care, treatment, and services related to each
category
HF - Staff Status Categories: - ANS -Membership categories
MCO acronym for - ANS -Managed Care Organization - main accreditors: NCQA, URAC
NAMSS acronym for - ANS -National Association of Medical Staff Services
CPCS acronym for - ANS -Certified Provider Credentialing Specialist
CVO acronym for - ANS -Credential Verifications Organization
HEDIS acronym for - ANS -Healthcare Effectiveness Data Information Set
CAHPS acronym for - ANS -Consumer Assessment of Healthcare Providers & Systems
Structure of a CVO - ANS -Director - Contract Sales - Credentialing Staff - Human Resources
Structure of a MCO - ANS -Director - Contracts Management - Client Services
- Financial Management - Network Admin
Definition of CVO per Industry terms - ANS -Commercial third party payers, healthcare
networks, and health plans
2 types of CVO - ANS -Organization Specific
Independent
Medicare CoPs (CCJET) - ANS -Character
Competence
Judgement
Experience
Training
Definition of Compliance - ANS -Comply with accredited atom and regulatory standards (i.e.
Audits, Obtain & evaluate sanctions, etc)
Reasons for Credentialing - ANS -Patient safety
Risk management
Accrediting & Regulatory Agencies
Definition of CoP's - ANS -Medicare Conditions of Participation: Code of Federal Regulations
intended to protect patient health & safety
,TJC - definition of Credentialing - ANS -Process of obtaining, verifying & assessing the
qualifications of a healthcare practitioner who seeks to provide patient care services for a
hospital
NCQA definition of Credentialing - ANS -Process by which an organization reviews and
evaluates qualifications of a LIP to provide services to its members
Reasons to get accredited - ANS -Quality of care
Accrediting bodies
Deemed Status - participation in Medicare/Medicaid
Liability insurance premiums
Managed care contracts
Unions may require for healthcare to employees
Basics of Bylaws - ANS -Unique to each hospital
Guidelines serve to ensure compliance
Regular review required
Bylaw changes not effective until board approved
State requirements may influence
CMS Rule for Governing Body - ANS -Governing Body has authority to approve/disapprove
bylaws suggested by med staff and revisions before approving
Rules & Regs - ANS -Detail what med staff appointees may or may not do
Med staff may delegate authority to change rules/regs to MEC
Hospital Credentialing Organizations - ANS -TJC, DNV, HFAP
Policies & Procedures - ANS -Describe course or conduct/action/management of a matter or
circumstance.
Often address internal matters
MCO Credentialing Organizations - ANS -NCQA, URAC
NCQA - Time limit for verification of Board Certification - ANS -180 days, 120 for CVO
URAC - Time limit for verification of Board Certification - ANS -6 months
AAAHC - Time limit for verification of Board Certification - ANS -Rule states: Verify on
application and on an ongoing basis
Definition of Licensure - ANS -A license is the authority a government agency grants an
individual to practice a profession
, Definition of State Licensure - ANS -Regulation of medical and other professional practice is a
state function. State exercises the regulation f medical practice through licensing laws, which
include both regulations of health work force and institutions
Medicare CoPs - License Verification - ANS -Hospital must assure that staff are licensed or
meet other standards required by state/local law. All staff required by state to be licensed must
possess a current license. Must ensure staff comply with state laws (vary from state to state)
NCQA Ceedentials? - ANS -LIP's (physician & non-physician)
Provide care to organization's members
Outside hospital setting
Free-standing ambulatory facilities
Hospital based who see members as result of independent relationship with org.
Rental network practitioners
Telemedicine with independent relationship
NCQA does not credential? - ANS -Providers exclusive to inpatient setting
Providers exclusive to free-standing facility with care as result of member being directed to
facility
Locums unless greater than 90 days
Board certified consultants
Rental network provider out-of-area care
URAC acronym for - ANS -Utilization Review Accreditation Commission
AAAHC acronym for - ANS -Accreditation Association for Ambulatory Healthcare
Who does AAAHC credential? - ANS -Do not specify which providers need to be credentialed
Governing body defines criteria for initial and reappointment of physicians and dentists
AAAHC Credentialing Criteria - ANS -Must have process that describes minimum requirements,
process to review/assess individual qualifications such as
Education, experience, cert, lic, competency
TJC - Staff Status Categories:
Interprets the word "Privileges" to mean - ANS -Duties and prerogatives of each category, and
not the clinical privileges to provide patient care, treatment, and services related to each
category
HF - Staff Status Categories: - ANS -Membership categories
