CPCS 2025: Questions
What bodies do not specifically address complaints? - ANS -TJC, ACHC, AAAHC
How often does NCQA require the evaluation of complaints? - ANS -All practitioners at least
every 6 months
What defines the mechanisms used for complaints according to URAC? - ANS -The policies
What is the credentialing committee responsible for in regard to Complaints for URAC? - ANS
-Reviews and discusses the performance data and identifies any trends.
According to the DNV, the organization is required to institute a standard grievance procedure
that incudes: - ANS -1. A list of those who should be contacted
2. How the governing body will review and resolve grievances
3. A process for referring quality of care issues to peer review, quality management, or
utilization review.
4. The timeframe during which patient grievances will be reviewed, responded to, and resolved
in a timely manner
5. A provision that the patient will receive a written grievance resolution that includes the
organizational contact, the steps involved in the investigation, the results, and the date the
process was completed.
What would cause CMS Managed Care to require a site visit as soon as possible? - ANS
-Complaints about the condition of the site that suggest compromised safety or other concerns
related to the delivery of care
CMS COP: Complaint - ANS -Hospital must establish a process for prompt resolution of patient
grievances and must inform each patient whom to contact to file a grievance
What bodies use the wording, "Require compliance with applicable regulations and law"? - ANS
-TJC, URAC, AAHC
CMS Managed Care + "State laws or regulations relating to inclusion or treatment of providers
are superseded by federal law, with the exception of state licensing laws and state laws
regarding plan solvency."
What bodies use the wording, " Require compliance with federal and state laws"? - ANS
-NCQA
DNV + organizational policies and procedures
, What bodies use the wording, " Require compliance with Medicare CoP, state laws, and local
laws"? - ANS -ACHC
What bodies use the wording, "comply with federal law, state law, and the requirements of the
CoP's" - ANS -CMS CoP
What bodies address Continuing Education? - ANS -TJC, ACHC, DNV
What bodies do not specifically address Continuing Education? - ANS -CMS COP, CMS
Managed Care, NCQA, URAC, AAAHC
What documentation of Continuing Education does the Joint Commision allow? - ANS -1.
Copies of program certificates
2. Copy of information submitted for license renewal
3. Obtaining an attestation from the LIP with the stipulation that proof of attendance and
program content will be submitted upon request
TJC: Continuing Education - ANS -1. LIP and other practitioners privileged through the medical
staff process
2. Participation must be documented and considered in decisions for reappointment, renewal, or
revision of clinical privileges.
ACHC may request Continuing Education evidence at what time? - ANS -Reappointment
Who does the DNV require to participate in Continuing Education? - ANS -All individuals with
delineated clinical privileges ( CE must be related in part to their clinical privileges)
Can the DNV place an application on hold if the practitioner does not have evidence of
Continuing Education? - ANS -Yes. Action on an individual's application for appointment or
reappointment, or initial or subsequent clinical privileges, is withheld until the information is
available and verified.
What bodies specifically address Criminal Background Checks? - ANS -CMS COP, TJC, ACHC
What bodies do not specifically address Criminal Background Checks? - ANS -DNV, CMC
Managed Care, NCQA, URAC, AAAHC
Who does the Joint Commission require to have a criminal background check? - ANS -Hospital
employees who provide care, treatment, and service
What do the standards for Joint Commission say about Criminal Background Checks? - ANS
-Obtained and documented for the applicant as required by state law, regulations, or
organizational policy
What bodies do not specifically address complaints? - ANS -TJC, ACHC, AAAHC
How often does NCQA require the evaluation of complaints? - ANS -All practitioners at least
every 6 months
What defines the mechanisms used for complaints according to URAC? - ANS -The policies
What is the credentialing committee responsible for in regard to Complaints for URAC? - ANS
-Reviews and discusses the performance data and identifies any trends.
According to the DNV, the organization is required to institute a standard grievance procedure
that incudes: - ANS -1. A list of those who should be contacted
2. How the governing body will review and resolve grievances
3. A process for referring quality of care issues to peer review, quality management, or
utilization review.
4. The timeframe during which patient grievances will be reviewed, responded to, and resolved
in a timely manner
5. A provision that the patient will receive a written grievance resolution that includes the
organizational contact, the steps involved in the investigation, the results, and the date the
process was completed.
What would cause CMS Managed Care to require a site visit as soon as possible? - ANS
-Complaints about the condition of the site that suggest compromised safety or other concerns
related to the delivery of care
CMS COP: Complaint - ANS -Hospital must establish a process for prompt resolution of patient
grievances and must inform each patient whom to contact to file a grievance
What bodies use the wording, "Require compliance with applicable regulations and law"? - ANS
-TJC, URAC, AAHC
CMS Managed Care + "State laws or regulations relating to inclusion or treatment of providers
are superseded by federal law, with the exception of state licensing laws and state laws
regarding plan solvency."
What bodies use the wording, " Require compliance with federal and state laws"? - ANS
-NCQA
DNV + organizational policies and procedures
, What bodies use the wording, " Require compliance with Medicare CoP, state laws, and local
laws"? - ANS -ACHC
What bodies use the wording, "comply with federal law, state law, and the requirements of the
CoP's" - ANS -CMS CoP
What bodies address Continuing Education? - ANS -TJC, ACHC, DNV
What bodies do not specifically address Continuing Education? - ANS -CMS COP, CMS
Managed Care, NCQA, URAC, AAAHC
What documentation of Continuing Education does the Joint Commision allow? - ANS -1.
Copies of program certificates
2. Copy of information submitted for license renewal
3. Obtaining an attestation from the LIP with the stipulation that proof of attendance and
program content will be submitted upon request
TJC: Continuing Education - ANS -1. LIP and other practitioners privileged through the medical
staff process
2. Participation must be documented and considered in decisions for reappointment, renewal, or
revision of clinical privileges.
ACHC may request Continuing Education evidence at what time? - ANS -Reappointment
Who does the DNV require to participate in Continuing Education? - ANS -All individuals with
delineated clinical privileges ( CE must be related in part to their clinical privileges)
Can the DNV place an application on hold if the practitioner does not have evidence of
Continuing Education? - ANS -Yes. Action on an individual's application for appointment or
reappointment, or initial or subsequent clinical privileges, is withheld until the information is
available and verified.
What bodies specifically address Criminal Background Checks? - ANS -CMS COP, TJC, ACHC
What bodies do not specifically address Criminal Background Checks? - ANS -DNV, CMC
Managed Care, NCQA, URAC, AAAHC
Who does the Joint Commission require to have a criminal background check? - ANS -Hospital
employees who provide care, treatment, and service
What do the standards for Joint Commission say about Criminal Background Checks? - ANS
-Obtained and documented for the applicant as required by state law, regulations, or
organizational policy
