CPCS CPCS - Certified Provider Credentialing Specialist Primary Source Verification Questions and Answers 2 — Questions and Answers
Question 1: Which of the following is considered an acceptable alternative to primary source verification for medical education when the original institution is no longer in existence?
- A copy of the diploma provided by the practitioner
- Verification through a recognized national repository such as the AMA Physician Master File or ECFMG (Correct answer)
- A letter from the state medical board confirming the degree
- A notarized affidavit from the practitioner
Correct answer: Verification through a recognized national repository such as the AMA Physician Master File or ECFMG
When a medical school no longer exists, recognized national repositories such as the AMA Physician Master File or ECFMG (for foreign graduates) that maintain historical education records are acceptable alternative PSV sources.
Primary source verification must be obtained from the original issuing institution. When an institution no longer exists (closed medical school, defunct residency program), accreditation standards recognize that direct PSV is impossible. In these cases, acceptable alternatives include recognized repositories that maintain historical records from closed institutions: the AMA Physician Master File for U.S. medical education, ECFMG for foreign medical education, and the Federation of State Medical Boards (FSMB) for licensure history. A diploma copy or practitioner affidavit is not acceptable PSV.
Question 2: Under NCQA credentialing standards, what is the maximum acceptable age of primary source verifications at the time the credentials committee reviews the file?
- 30 days
- 90 days
- 180 days (Correct answer)
- 365 days
Correct answer: 180 days
NCQA requires that primary source verifications be no more than 180 days old at the time of the credentialing committee review or the approval decision.
NCQA CR 2 requires that primary source verification be current, specifically no more than 180 days old at the time of the credentialing decision. This means that if verification is obtained and the committee review is delayed beyond 180 days, the verification must be obtained again. This requirement ensures that the committee is making decisions based on current information, not outdated verifications that might not reflect recent license actions or adverse events.
Question 3: A credentialing specialist is verifying a physician's residency training. The residency program director is no longer with the program. Who else can provide primary source verification of residency completion?
- The physician themselves, via a signed statement
- The current program director or program administrator, as designated representatives of the program (Correct answer)
- The national residency match program (NRMP)
- Another physician who was a co-resident during the same period
Correct answer: The current program director or program administrator, as designated representatives of the program
The current program director or program administrator/coordinator, as authorized representatives of the sponsoring institution, can provide primary source verification of residency completion even if the original program director has left.
When the original residency program director is no longer with the program, primary source verification can be obtained from: (1) the current program director (who has access to program records), (2) the program administrator or training coordinator (as authorized institutional representatives), (3) the graduate medical education (GME) office of the sponsoring institution, or (4) in some cases, the AMA GME database if it contains the program records. Co-residents are not authorized institutional sources, and practitioner self-certification is never acceptable for PSV.
Question 4: What is the significance of verifying a practitioner's malpractice insurance through the insurance carrier rather than accepting a certificate of insurance from the practitioner?
- Insurance carriers charge less for direct verification
- Direct carrier verification confirms current active coverage and may reveal pending cancellations or coverage limits changes (Correct answer)
- The certificate of insurance format cannot be accepted by credentialing databases
- Direct carrier verification is only required for new practitioners
Correct answer: Direct carrier verification confirms current active coverage and may reveal pending cancellations or coverage limits changes
Direct verification with the insurance carrier confirms that coverage is currently active, the policy has not been cancelled or modified, and the stated limits are accurate, information that a practitioner-provided certificate may not reflect.
A certificate of insurance provides a snapshot of coverage at a point in time but may not reflect current status. By verifying directly with the insurance carrier, the credentialing specialist can confirm: (1) the policy is currently active and has not been cancelled, (2) the practitioner named is the insured, (3) the coverage limits are as stated, (4) there are no pending cancellation notices, and (5) the policy covers the type of practice described in the application. This is particularly important because carriers may cancel policies for non-payment or other reasons without the practitioner immediately notifying the medical staff office.
Question 5: Which of the following verification sources is considered a 'recognized equivalent' to primary source verification under NCQA standards?
- A practitioner-provided copy of their license
- A verification service that contacts primary sources on behalf of the credentialing organization (Correct answer)
- An insurance company's verification of the practitioner's education
- A colleague's verbal attestation to the practitioner's qualifications
Correct answer: A verification service that contacts primary sources on behalf of the credentialing organization
Under NCQA standards, a recognized equivalent is an agent or intermediary that obtains information directly from the primary source, such as a credentials verification organization (CVO) that contacts primary sources on behalf of the credentialing organization.
NCQA recognizes that direct PSV can be impractical for all elements in all circumstances. A 'recognized equivalent' is a process that provides the same level of assurance as direct PSV. This includes: (1) certified credentials verification organizations (CVOs) that contact primary sources on behalf of the credentialing organization, (2) state licensing board online verification databases (where the state board maintains the data), and (3) approved national databases (like the AMA Masterfile for education). The key is that the information comes from or is verified by the actual issuing source, not from the practitioner or an intermediary that does not contact the source.
Question 6: A state medical board's online license verification database is updated in real-time and indicates a physician's license is 'Active.' Does this constitute primary source verification of licensure?
- No, primary source verification always requires a written letter from the medical board
- Yes, a real-time database maintained by the licensing authority constitutes primary source verification (Correct answer)
- No, online verification is not acceptable for NCQA purposes
- Yes, but only if printed and signed by a credentialing specialist
Correct answer: Yes, a real-time database maintained by the licensing authority constitutes primary source verification
A real-time online database maintained by the licensing authority (such as a state medical board website) constitutes primary source verification because the data comes directly from the issuing source.
NCQA and most accreditation standards recognize that online verification databases maintained by licensing authorities constitute primary source verification, provided the database is real-time or regularly updated. A written letter is not always required. The state medical board maintains the authoritative data about license status — its online portal is simply a delivery mechanism for that authoritative data. The credentialing specialist should document the date of verification, the source (specific website URL), and the results, and retain evidence of the verification.
CPCS CPCS - Certified Provider Credentialing Specialist Primary Source Verification Questions and Answers 2
Which of the following is considered an acceptable alternative to primary source verification for medical education when the original institution is no longer in existence?