NAMSS CPCS PARTICIPATION EXAM GUIDE

NAMSS CPCS PARTICIPATION EXAM
GUIDE

Credentialing at Hospitals Driven by: - ANSWER - Federal/State Regulations
- CMS
- Hospital CoPs
- HCQIA
- Accreditation Standards
- TJC
- HFAP
- DNV
-Bylaws, Rules and Regs
-Standard of Care (legal aspect)


Managed Care Org Credentialing Driven by: - ANSWER -Federal/State
Regulations
-Policies and Procedures
-Accreditation Standards (NCQA, URAC)
-Standard of Care (legal aspect)
-HEDIS/CAHPS


MCO Organization Chart - ANSWER Director of Managed Care
Contracts Management --> Client Services
Financial Management --->Network Administration

, CVO Organizational Chart - ANSWER (depending on size)
Director ---> Contract sales/Credentialing Staff/Human Resources


CVO Credentialing Driven by: - ANSWER - Contract
- Accredidation Standards (NCQA, URAC,TJC,AAAHC, CMS, HFAP &
DNV)
-Policies and Procedures


Ambulatory Care/Medical Office/Surgical Center Credentialing Driven by: -
ANSWER - Accreditation Standards (AAAHC, TJC, NCQA)
- CMS Regulations
- State law
- Policies and Procedures
- Contractual Agreements


What drives hospital credentialing? - ANSWER - Federal/State Regulations
- CMS
- Hospital CoPs
- HCQIA
- Accreditation Standards
- TJC
- HFAP
- DNV
-Bylaws, Rules and Regs
-Standard of Care (legal aspect)