CPCS – NAMSS QUESTIONS AND ANSWERS
Ability to Perform Clinical Privileges Requested (Health Status):
Who requires a current signed attestation from applicant regarding the reasons for any
inability to perform essential functions of the position with/without accommodation and
the lack of present illegal drug use? - Answers - NCQA
Ability to Perform Clinical Privileges Requested (Health Status):
Which body states surgical privileges shall correspond with the established
competencies of each practitioner? - Answers - DNV
Ability to Perform Clinical Privileges Requested (Health Status):
Who requires that the applicant's ability to perform privileges requested must be
evaluated and this evaluation documented in the credentials file? - Answers - TJC
Ability to Perform Clinical Privileges Requested (Health Status):
Who states references should include a statement regarding the physician's physical
and mental health in relation to privileges requested? - Answers - HFAP
Ability to Perform Clinical Privileges Requested (Health Status):
Who states application includes disclosure of any physical, mental or substance abuse
problems..... - Answers - URAC
Ability to Perform Clinical Privileges Requested (Health Status):
The DNV's surveyor's guidance section mirrors who? - Answers - Medicare COPs
Allied Health Professionals/Non-physician practitioners:
Which bodies use the term Allied Health Professionals? - Answers - URAC, AAAHC
Allied Health Professionals/Non-physician practitioners:
The Joint Commission states any individual permitted by law and by the organization to
provide care, treatment and services without direction or supervision is known as what?
- Answers - Licensed Independent Practitioner
Allied Health Professionals/Non-physician practitioners:
,If allowed by the organization, _____________ states the board must provide a process
for the initial appointment, reappointment, assignment or curtailment of privileges and
practice for AHP's. - Answers - AAAHC
Who states all patients must be under the care of a member of the medical staff or
under the care of a practitioner who is directly under the supervision of a member of the
medical staff? - Answers - DNV
Allied Health Professionals/Non-physician practitioners:
TJC states all LIP PAs and APRN's who are providing a medical level of care are
credentialed and privileged through? - Answers - The Medical Staff Process
Applicant Identity:
Who requires a mechanism to determine the applicant is the individual identified in the
credentialing documents by viewing either a current picture hospital ID card or a valid
picture ID issued by a state or federal agency (driver's license or passport) - Answers -
TJC
Applicant Identity:
Who requires verification of identity to be performed prior to the practitioner providing
patient care services? - Answers - TJC
Applicant Identity:
Who is the only body with applicant identity requirements? - Answers - TJC
Applicant Identity:
TJC allowed identity verification to be performed in person or through the use of
telecommunication such as an audio call - Answers - False
Appointment timeframe:
TJC states appointment is not to exceed ___________ measured by the day? -
Answers - 3 years
Appointment timeframe:
Which accrediting body's appointment timeframe requirements are a direct quote from
CMS? - Answers - HFAP
Appointment timeframe:
,Which accrediting bodies recredential at least every three years and counts the three
year cycle to the month not the day? - Answers - NCQA, URAC
Appointment timeframe:
Appointment timeframes with ______________ are defined by State law and
organizational policy and are not to exceed three years? - Answers - AAAHC
Appointment timeframe:
TJC states appointments are not to exceed two years and are measured to the month -
Answers - False
Appointment timeframe:
Both NCQA and URAC recredential at least every 3 years and count to the month not
the day - Answers - True
Study Guide Questions:
What does NAMSS stand for? - Answers - National Association Medical Staff Services
NAMSS membership includes more than __________ medical staff and credentialing
services professionals - Answers - 6000
Study Guide Questions:
Who defines credentialing as the process of obtaining, verifying and assessing the
qualifications of a healthcare practitioner who seeks to provide patient care services in
or for a hospital? - Answers - TJC
Study Guide Questions:
Who defines credentialing as a process by which an organization reviews and evaluates
qualifications of licensed independent practitioners to provide services to its members? -
Answers - NCQA
Study Guide Questions:
What is the number one concern for credentialing? - Answers - Patient Safety
Study Guide Questions:
Where are the Medicare Conditions of Participation (COPs) contained? - Answers -
Code of Federal Regulations
, Study Guide Questions:
_____________________________ are intended to protect patient health and safety
and to ensure quality of care for hospitalized patients - Answers - Medicare COPs
Study Guide Questions:
Organizations that are accredited by recognized entities are given what? - Answers -
Deemed status
Study Guide Questions:
In order for an accreditor to receive deemed status they must do what? - Answers -
Submit their standards to CMS for approval
Study Guide Questions:
The medical staff exists as an extension of the healthcare facility and is considered
what? - Answers - A self-governing entity
Study Guide Questions:
________________ detail what medical staff appointees may or may not do - Answers
- Rules and Regulations
Study Guide Questions:
________________ describe the course of conduct or action pursued or the
management of a matter in certain circumstances - Answers - Policies and Procedures
Study Guide Questions:
Managed Care Organizations use _________________ to delineate required functions -
Answers - Policies and Procedures
Aspect 5 - Attestation Statement:
Which of the following responsibilities does HFAP not require practitioners to attest to? -
Answers - The practitioner does not discriminate
Aspect 5 - Attestation Statement:
NCQA requires that the attestation is received prior to the organization conducting
credentialing verifications and queries required for other elements - Answers - False
Aspect 5 - Attestation Statement:
Ability to Perform Clinical Privileges Requested (Health Status):
Who requires a current signed attestation from applicant regarding the reasons for any
inability to perform essential functions of the position with/without accommodation and
the lack of present illegal drug use? - Answers - NCQA
Ability to Perform Clinical Privileges Requested (Health Status):
Which body states surgical privileges shall correspond with the established
competencies of each practitioner? - Answers - DNV
Ability to Perform Clinical Privileges Requested (Health Status):
Who requires that the applicant's ability to perform privileges requested must be
evaluated and this evaluation documented in the credentials file? - Answers - TJC
Ability to Perform Clinical Privileges Requested (Health Status):
Who states references should include a statement regarding the physician's physical
and mental health in relation to privileges requested? - Answers - HFAP
Ability to Perform Clinical Privileges Requested (Health Status):
Who states application includes disclosure of any physical, mental or substance abuse
problems..... - Answers - URAC
Ability to Perform Clinical Privileges Requested (Health Status):
The DNV's surveyor's guidance section mirrors who? - Answers - Medicare COPs
Allied Health Professionals/Non-physician practitioners:
Which bodies use the term Allied Health Professionals? - Answers - URAC, AAAHC
Allied Health Professionals/Non-physician practitioners:
The Joint Commission states any individual permitted by law and by the organization to
provide care, treatment and services without direction or supervision is known as what?
- Answers - Licensed Independent Practitioner
Allied Health Professionals/Non-physician practitioners:
,If allowed by the organization, _____________ states the board must provide a process
for the initial appointment, reappointment, assignment or curtailment of privileges and
practice for AHP's. - Answers - AAAHC
Who states all patients must be under the care of a member of the medical staff or
under the care of a practitioner who is directly under the supervision of a member of the
medical staff? - Answers - DNV
Allied Health Professionals/Non-physician practitioners:
TJC states all LIP PAs and APRN's who are providing a medical level of care are
credentialed and privileged through? - Answers - The Medical Staff Process
Applicant Identity:
Who requires a mechanism to determine the applicant is the individual identified in the
credentialing documents by viewing either a current picture hospital ID card or a valid
picture ID issued by a state or federal agency (driver's license or passport) - Answers -
TJC
Applicant Identity:
Who requires verification of identity to be performed prior to the practitioner providing
patient care services? - Answers - TJC
Applicant Identity:
Who is the only body with applicant identity requirements? - Answers - TJC
Applicant Identity:
TJC allowed identity verification to be performed in person or through the use of
telecommunication such as an audio call - Answers - False
Appointment timeframe:
TJC states appointment is not to exceed ___________ measured by the day? -
Answers - 3 years
Appointment timeframe:
Which accrediting body's appointment timeframe requirements are a direct quote from
CMS? - Answers - HFAP
Appointment timeframe:
,Which accrediting bodies recredential at least every three years and counts the three
year cycle to the month not the day? - Answers - NCQA, URAC
Appointment timeframe:
Appointment timeframes with ______________ are defined by State law and
organizational policy and are not to exceed three years? - Answers - AAAHC
Appointment timeframe:
TJC states appointments are not to exceed two years and are measured to the month -
Answers - False
Appointment timeframe:
Both NCQA and URAC recredential at least every 3 years and count to the month not
the day - Answers - True
Study Guide Questions:
What does NAMSS stand for? - Answers - National Association Medical Staff Services
NAMSS membership includes more than __________ medical staff and credentialing
services professionals - Answers - 6000
Study Guide Questions:
Who defines credentialing as the process of obtaining, verifying and assessing the
qualifications of a healthcare practitioner who seeks to provide patient care services in
or for a hospital? - Answers - TJC
Study Guide Questions:
Who defines credentialing as a process by which an organization reviews and evaluates
qualifications of licensed independent practitioners to provide services to its members? -
Answers - NCQA
Study Guide Questions:
What is the number one concern for credentialing? - Answers - Patient Safety
Study Guide Questions:
Where are the Medicare Conditions of Participation (COPs) contained? - Answers -
Code of Federal Regulations
, Study Guide Questions:
_____________________________ are intended to protect patient health and safety
and to ensure quality of care for hospitalized patients - Answers - Medicare COPs
Study Guide Questions:
Organizations that are accredited by recognized entities are given what? - Answers -
Deemed status
Study Guide Questions:
In order for an accreditor to receive deemed status they must do what? - Answers -
Submit their standards to CMS for approval
Study Guide Questions:
The medical staff exists as an extension of the healthcare facility and is considered
what? - Answers - A self-governing entity
Study Guide Questions:
________________ detail what medical staff appointees may or may not do - Answers
- Rules and Regulations
Study Guide Questions:
________________ describe the course of conduct or action pursued or the
management of a matter in certain circumstances - Answers - Policies and Procedures
Study Guide Questions:
Managed Care Organizations use _________________ to delineate required functions -
Answers - Policies and Procedures
Aspect 5 - Attestation Statement:
Which of the following responsibilities does HFAP not require practitioners to attest to? -
Answers - The practitioner does not discriminate
Aspect 5 - Attestation Statement:
NCQA requires that the attestation is received prior to the organization conducting
credentialing verifications and queries required for other elements - Answers - False
Aspect 5 - Attestation Statement:
