CPCS CPCS - Certified Provider Credentialing Specialist Payor Credentialing and Delegation Questions and Answers 1 — Questions and Answers
Question 1: What is payor credentialing in the context of healthcare provider enrollment?
- The process by which a health plan verifies a provider's qualifications before allowing them to participate in the plan's network (Correct answer)
- The process of granting clinical privileges at a hospital
- The verification of a provider's malpractice insurance coverage only
- The initial application processing step at a healthcare facility
Correct answer: The process by which a health plan verifies a provider's qualifications before allowing them to participate in the plan's network
Payor credentialing is the health plan's process of verifying provider credentials to establish network participation and enable claims reimbursement.
Question 2: What is credentialing delegation in managed care?
- A formal arrangement where a health plan authorizes an organization (e.g., a hospital or medical group) to perform credentialing functions on the plan's behalf (Correct answer)
- The transfer of credentialing responsibility from one credentialing specialist to another within an organization
- A state regulatory requirement to outsource credentialing to a third party
- The process of delegating clinical privileges from one practitioner to another
Correct answer: A formal arrangement where a health plan authorizes an organization (e.g., a hospital or medical group) to perform credentialing functions on the plan's behalf
Credentialing delegation allows a health plan to formally authorize an external entity to conduct credentialing activities, subject to oversight and audit.
Question 3: Which accreditation body sets widely recognized standards for health plan credentialing delegation programs?
- NCQA (National Committee for Quality Assurance) (Correct answer)
- The Joint Commission (TJC)
- URAC
- CMS only
Correct answer: NCQA (National Committee for Quality Assurance)
NCQA's health plan accreditation standards are the most widely referenced framework for managed care credentialing and delegation requirements in the U.S.
Question 4: Under NCQA delegation standards, how often must a health plan conduct an audit of a delegated credentialing entity?
- At least annually (Correct answer)
- Every two years
- Every three years
- Only at the initial delegation agreement signing
Correct answer: At least annually
NCQA requires health plans to audit delegated credentialing organizations at least annually to ensure compliance with delegation agreement requirements.
Question 5: What must a delegation agreement between a health plan and a delegated entity include?
- Scope of delegated functions, performance standards, audit rights, and remedies for non-compliance (Correct answer)
- Only the list of providers covered under the agreement
- The health plan's internal credentialing policies without modification rights
- A waiver of the entity's right to appeal credentialing decisions
Correct answer: Scope of delegated functions, performance standards, audit rights, and remedies for non-compliance
A delegation agreement must define the scope of delegated activities, set performance expectations, grant audit rights, and specify corrective action for non-compliance.
Question 6: What is the typical timeframe that health plans (and NCQA standards) allow for completing initial credentialing of a provider after receipt of a complete application?
- 180 days (Correct answer)
- 30 days
- 90 days
- 365 days
Correct answer: 180 days
NCQA standards generally allow up to 180 days to complete initial credentialing from receipt of a complete application.
CPCS CPCS - Certified Provider Credentialing Specialist Payor Credentialing and Delegation Questions and Answers 1
What is payor credentialing in the context of healthcare provider enrollment?