CPMSM 2025/2026 QUESTIONS AND ANSWERS
GUARANTEE A+
✔✔What type of procedure would be routinely performed by a cardiologist? -
✔✔Transesophageal Echocardiography
✔✔Which NCQA-required committee makes recommendations regarding credentialing
decisions? - ✔✔Credentialing Committee
✔✔HFAP standards require three medical staff committees to be delineated in the
medical staff structure. Two of
them are the Medical Executive Committee and the Utilization of Osteopathic Methods
& Concepts Committee
(required for hospitals with ten or more DOs who admit patients and provide direct
patient care). What is the
other required medical staff committee? - ✔✔Utilization Review Committee
✔✔If you needed to find out about what the Federal Government requires in regards to
anti-trust issues, what law
would you consult? - ✔✔Sherman Anti-trust Act
✔✔Peer references should be obtained from - ✔✔Practitioners in the same professional
discipline as the applicant
✔✔Patrick v. Burgett is an important case because it: - ✔✔Illustrates the potential for
antitrust liability arising out of peer review activities
✔✔If a medical staff member has privileges and/or medical staff appointment revoked,
he/she must be: - ✔✔Provided due process
✔✔Access to credentials files should be: - ✔✔Described fully in an access policy
✔✔What body approves clinical privileges? - ✔✔Governing Body or Board
✔✔What primary source verification is required by NCQA prior to provisional
credentialing? - ✔✔Licensure and 5 year malpractice history or NPDB
✔✔According to The Joint Commission standards, initial appointments to the medical
staff are made for a period of: - ✔✔Not to exceed two years
✔✔According to The Joint Commission standards, temporary privileges may be granted
by: - ✔✔The CEO on the recommendation of the medical staff president or authorized
designee
,✔✔According to The Joint Commission Standards, what must be verified with a primary
source? - ✔✔Licensure, training, experience, and competence
✔✔According to NCQA standards, a copy of what is an acceptable verification of the
document? - ✔✔DEA certificate
✔✔According to NCQA standards, what organization is an acceptable source for
primary source verification of Medicare and
Medicaid sanction activity against physicians? - ✔✔Federation of State Medical Boards
✔✔According to The Joint Commission standards, which organization is considered a
designated equivalent source
for verification of board certification? - ✔✔The American Board of Medical Specialties
✔✔What organization has been recognized by The Joint Commission and NCQA to
provide primary source verification of medical school graduation and residency training
for U.S. graduates? - ✔✔American Medical Association Masterfile
✔✔According to N CQA standards, the application attestation statement must affirm
that the application - ✔✔Is correct and complete
✔✔According to The Joint Commission standards, medical staff bylaws should define -
✔✔The structure of the medical staff
✔✔According to The Joint Commission hospital standards, professional criteria for the
granting of clinical privileges
must include at least - ✔✔Relevant training or experience, ability to perform privileges
requested, current licensure, and competence
✔✔The Joint Commission hospital standards require medical staff bylaws to include -
✔✔A mechanism for selection and removal of officers
✔✔According to NCQA standards, name an approved source for verification of board
certification? - ✔✔State licensing agency if state agency conducts primary verification of
board status
✔✔According to The Joint Commission hospital standards, which of the following is a
required component of the
reappointment process? - ✔✔Documentation of the applicant's health status
✔✔According to URAC's health network standards, each applicant within the scope of
the credentialing program
,submits an application that includes at least what: - ✔✔State licensure information,
including current license(s) and history of licensure in all jurisdictions
✔✔According to AAAHC, what must be monitored on an ongoing basis? - ✔✔Current
licensure
✔✔According to The Joint Commission, a nurse practitioner functioning independently
and providing a medical
level of care must: - ✔✔Be granted delineated clinical privileges
✔✔According to The Joint Commission, which organization is an acceptable source for
verification for medical
education of an international graduate? - ✔✔Education Commission for Foreign Medical
Graduates
✔✔When evaluating compliance with the required time-frame for recredentialing, NCQA
counts the recredentialing
period to the: - ✔✔Month
✔✔NCQA standards require the organization to verify board certification at
recredentialing: - ✔✔In all cases
✔✔To whom does the AAAHC give the responsibility for approving and ensuring
compliance with policies and
procedures related to credentialing, quality improvement, and risk management? -
✔✔Governing body
✔✔According to The Joint Commission hospital standards, which of the following is an
element of a self-governing
medical staff? - ✔✔The medical staff determines the mechanism for establishing and
enforcing criteria for assigning oversight
responsibilities to practitioners with independent privileges.
✔✔Robert's Rule of order is an example of - ✔✔Parliamentary procedure
✔✔The medical staff application should provide a chronological history of - ✔✔The
applicant's education, training, and work history
✔✔In order to participate in a managed care plan, a provider must be accepted to the
plan's - ✔✔Provider panel
✔✔In order for a physician to practice medicine in any state in the United States, he/she
must possess - ✔✔Current state licensure
, ✔✔What is considered post-graduate education? - ✔✔Residency training
✔✔What may not be used to evaluate credentials of applicants? - ✔✔Gender
✔✔The release of liability statement signed by the applicant for medical staff
appointment should include: - ✔✔A statement providing immunity to those who respond
in good faith to requests for information
✔✔Primary source verification is: - ✔✔Receiving information directly from the issuing
source
✔✔Unexplained delays between graduation and medical school, incomplete training,
and unexplained lapses in
professional practice are examples of: - ✔✔Red Flags
✔✔When documenting a telephone conversation regarding primary source verification
what should be documented? - ✔✔Name of person and organization contacted, date of
call, what was discussed and who conducted the
interview
✔✔According to HFAP standards, when confirming malpractice coverage the
organization must: - ✔✔Have evidence of professional liability insurance, which
includes certificate showing amounts of coverage
✔✔Which type of providers are considered a primary care physician (PCP)? -
✔✔General Practitioners, Internal Medicine, Obstetrics and Gynocology
✔✔Which body has the obligation to the community to assure that only appropriately
educated, trained and currently
competent practitioners are granted medical staff membership and clinical privileges? -
✔✔Governing Body
✔✔When credentialing and privileging practitioners it is appropriate to: - ✔✔Handle
each applicant on a case-by-case basis
✔✔Medical liability insurance should be held in what limits? - ✔✔As specified by the
medical staff and board of directors
✔✔Is this an appropriate question to ask on an application for Medical Staff...Do you
have any medical conditions, treated or untreated, that would negatively affect your
ability to
provide the services or perform the privileges you are requesting? - ✔✔Yes
GUARANTEE A+
✔✔What type of procedure would be routinely performed by a cardiologist? -
✔✔Transesophageal Echocardiography
✔✔Which NCQA-required committee makes recommendations regarding credentialing
decisions? - ✔✔Credentialing Committee
✔✔HFAP standards require three medical staff committees to be delineated in the
medical staff structure. Two of
them are the Medical Executive Committee and the Utilization of Osteopathic Methods
& Concepts Committee
(required for hospitals with ten or more DOs who admit patients and provide direct
patient care). What is the
other required medical staff committee? - ✔✔Utilization Review Committee
✔✔If you needed to find out about what the Federal Government requires in regards to
anti-trust issues, what law
would you consult? - ✔✔Sherman Anti-trust Act
✔✔Peer references should be obtained from - ✔✔Practitioners in the same professional
discipline as the applicant
✔✔Patrick v. Burgett is an important case because it: - ✔✔Illustrates the potential for
antitrust liability arising out of peer review activities
✔✔If a medical staff member has privileges and/or medical staff appointment revoked,
he/she must be: - ✔✔Provided due process
✔✔Access to credentials files should be: - ✔✔Described fully in an access policy
✔✔What body approves clinical privileges? - ✔✔Governing Body or Board
✔✔What primary source verification is required by NCQA prior to provisional
credentialing? - ✔✔Licensure and 5 year malpractice history or NPDB
✔✔According to The Joint Commission standards, initial appointments to the medical
staff are made for a period of: - ✔✔Not to exceed two years
✔✔According to The Joint Commission standards, temporary privileges may be granted
by: - ✔✔The CEO on the recommendation of the medical staff president or authorized
designee
,✔✔According to The Joint Commission Standards, what must be verified with a primary
source? - ✔✔Licensure, training, experience, and competence
✔✔According to NCQA standards, a copy of what is an acceptable verification of the
document? - ✔✔DEA certificate
✔✔According to NCQA standards, what organization is an acceptable source for
primary source verification of Medicare and
Medicaid sanction activity against physicians? - ✔✔Federation of State Medical Boards
✔✔According to The Joint Commission standards, which organization is considered a
designated equivalent source
for verification of board certification? - ✔✔The American Board of Medical Specialties
✔✔What organization has been recognized by The Joint Commission and NCQA to
provide primary source verification of medical school graduation and residency training
for U.S. graduates? - ✔✔American Medical Association Masterfile
✔✔According to N CQA standards, the application attestation statement must affirm
that the application - ✔✔Is correct and complete
✔✔According to The Joint Commission standards, medical staff bylaws should define -
✔✔The structure of the medical staff
✔✔According to The Joint Commission hospital standards, professional criteria for the
granting of clinical privileges
must include at least - ✔✔Relevant training or experience, ability to perform privileges
requested, current licensure, and competence
✔✔The Joint Commission hospital standards require medical staff bylaws to include -
✔✔A mechanism for selection and removal of officers
✔✔According to NCQA standards, name an approved source for verification of board
certification? - ✔✔State licensing agency if state agency conducts primary verification of
board status
✔✔According to The Joint Commission hospital standards, which of the following is a
required component of the
reappointment process? - ✔✔Documentation of the applicant's health status
✔✔According to URAC's health network standards, each applicant within the scope of
the credentialing program
,submits an application that includes at least what: - ✔✔State licensure information,
including current license(s) and history of licensure in all jurisdictions
✔✔According to AAAHC, what must be monitored on an ongoing basis? - ✔✔Current
licensure
✔✔According to The Joint Commission, a nurse practitioner functioning independently
and providing a medical
level of care must: - ✔✔Be granted delineated clinical privileges
✔✔According to The Joint Commission, which organization is an acceptable source for
verification for medical
education of an international graduate? - ✔✔Education Commission for Foreign Medical
Graduates
✔✔When evaluating compliance with the required time-frame for recredentialing, NCQA
counts the recredentialing
period to the: - ✔✔Month
✔✔NCQA standards require the organization to verify board certification at
recredentialing: - ✔✔In all cases
✔✔To whom does the AAAHC give the responsibility for approving and ensuring
compliance with policies and
procedures related to credentialing, quality improvement, and risk management? -
✔✔Governing body
✔✔According to The Joint Commission hospital standards, which of the following is an
element of a self-governing
medical staff? - ✔✔The medical staff determines the mechanism for establishing and
enforcing criteria for assigning oversight
responsibilities to practitioners with independent privileges.
✔✔Robert's Rule of order is an example of - ✔✔Parliamentary procedure
✔✔The medical staff application should provide a chronological history of - ✔✔The
applicant's education, training, and work history
✔✔In order to participate in a managed care plan, a provider must be accepted to the
plan's - ✔✔Provider panel
✔✔In order for a physician to practice medicine in any state in the United States, he/she
must possess - ✔✔Current state licensure
, ✔✔What is considered post-graduate education? - ✔✔Residency training
✔✔What may not be used to evaluate credentials of applicants? - ✔✔Gender
✔✔The release of liability statement signed by the applicant for medical staff
appointment should include: - ✔✔A statement providing immunity to those who respond
in good faith to requests for information
✔✔Primary source verification is: - ✔✔Receiving information directly from the issuing
source
✔✔Unexplained delays between graduation and medical school, incomplete training,
and unexplained lapses in
professional practice are examples of: - ✔✔Red Flags
✔✔When documenting a telephone conversation regarding primary source verification
what should be documented? - ✔✔Name of person and organization contacted, date of
call, what was discussed and who conducted the
interview
✔✔According to HFAP standards, when confirming malpractice coverage the
organization must: - ✔✔Have evidence of professional liability insurance, which
includes certificate showing amounts of coverage
✔✔Which type of providers are considered a primary care physician (PCP)? -
✔✔General Practitioners, Internal Medicine, Obstetrics and Gynocology
✔✔Which body has the obligation to the community to assure that only appropriately
educated, trained and currently
competent practitioners are granted medical staff membership and clinical privileges? -
✔✔Governing Body
✔✔When credentialing and privileging practitioners it is appropriate to: - ✔✔Handle
each applicant on a case-by-case basis
✔✔Medical liability insurance should be held in what limits? - ✔✔As specified by the
medical staff and board of directors
✔✔Is this an appropriate question to ask on an application for Medical Staff...Do you
have any medical conditions, treated or untreated, that would negatively affect your
ability to
provide the services or perform the privileges you are requesting? - ✔✔Yes
