CPCS CPCS Allied Health Professional Credentialing and Privileging 1 — Questions and Answers
Question 1: Which document serves as the primary reference for defining the scope of practice for allied health professionals during the credentialing process?
- State licensure act or practice act (Correct answer)
- The Joint Commission Comprehensive Accreditation Manual
- Hospital administrative policy manual
- CMS Conditions of Participation only
Correct answer: State licensure act or practice act
State licensure or practice acts define the legal scope of practice for allied health professionals and serve as the foundational reference during credentialing.
Question 2: When privileging a Physician Assistant (PA) in a hospital setting, which requirement is unique compared to privileging a physician?
- PAs must have a supervising or collaborating physician agreement on file (Correct answer)
- PAs do not require primary source verification
- PAs bypass the credentials committee review
- PAs only need state licensure, not DEA registration
Correct answer: PAs must have a supervising or collaborating physician agreement on file
PAs must have a documented supervising or collaborating physician agreement because their practice is legally dependent on physician oversight in most states.
Question 3: An allied health professional submits an application for clinical privileges but their profession is not listed in the medical staff bylaws. What is the FIRST step the credentialing specialist should take?
- Refer the matter to the medical staff leadership for bylaw review and amendment (Correct answer)
- Deny the application immediately
- Grant provisional privileges pending future review
- Forward directly to the CEO for approval
Correct answer: Refer the matter to the medical staff leadership for bylaw review and amendment
Bylaws must be amended to include a new category of allied health professionals before privileges can be granted, requiring medical staff leadership action.
Question 4: Which body typically has final approval authority for granting clinical privileges to allied health professionals at an accredited hospital?
- Governing board (Correct answer)
- Credentials committee
- Chief Medical Officer
- Department chair
Correct answer: Governing board
Under accreditation standards, the governing board holds ultimate authority for approving clinical privileges for all practitioners.
Question 5: A Certified Registered Nurse Anesthetist (CRNA) applies for privileges to perform regional anesthesia independently. Which accreditation standard is MOST relevant to the hospital's decision?
- The Joint Commission MS.06 standards on delineation of privileges (Correct answer)
- OSHA bloodborne pathogen standards
- CMS billing and coding regulations
- HIPAA privacy rule for patient records
Correct answer: The Joint Commission MS.06 standards on delineation of privileges
TJC MS.06 standards govern the delineation of privileges for all licensed independent and dependent practitioners, including CRNAs.
Question 6: What is the primary purpose of a 'focused professional practice evaluation' (FPPE) specifically for a newly credentialed allied health professional?
- To verify competency in requested privileges before granting full unrestricted privileges (Correct answer)
- To fulfill annual peer review requirements
- To comply with state reporting mandates
- To document malpractice history
Correct answer: To verify competency in requested privileges before granting full unrestricted privileges
FPPE for new practitioners establishes a defined monitoring period to confirm competency before converting to the ongoing OPPE process.
CPCS CPCS Allied Health Professional Credentialing and Privileging 1
Which document serves as the primary reference for defining the scope of practice for allied health professionals during the credentialing process?