CPCS Basic 2 — Questions and Answers
Question 1: Which organization accredits managed care organizations and sets credentialing standards that many health plans follow?
- The Joint Commission
- NCQA (Correct answer)
- URAC
- AAAHC
Correct answer: NCQA
NCQA (National Committee for Quality Assurance) accredits managed care organizations and its credentialing standards are widely adopted by health plans.
Question 2: What is the primary purpose of the National Practitioner Data Bank (NPDB)?
- To store physician tax records
- To track malpractice payments and adverse actions against practitioners (Correct answer)
- To verify medical school diplomas
- To manage Medicare enrollment
Correct answer: To track malpractice payments and adverse actions against practitioners
The NPDB collects and reports malpractice payments, licensure actions, and other adverse actions to prevent practitioners from moving between states to escape poor performance histories.
Question 3: Under NCQA standards, how often must a credentialed provider be re-credentialed?
- Every year
- Every two years
- Every three years (Correct answer)
- Every five years
Correct answer: Every three years
NCQA requires re-credentialing at least every three years to ensure provider information remains current and accurate.
Question 4: Which document grants a physician the right to perform specific clinical procedures at a hospital?
- Medical staff bylaws
- Delineation of privileges (Correct answer)
- Credentialing application
- Provider enrollment form
Correct answer: Delineation of privileges
Delineation of privileges (clinical privileges) specifies exactly which procedures and patient care activities a practitioner is authorized to perform at that facility.
Question 5: What does the term 'primary source verification' mean in credentialing?
- Reviewing a copy submitted by the applicant
- Contacting the original issuing organization directly to confirm credentials (Correct answer)
- Checking a national database aggregator
- Reviewing a peer reference letter
Correct answer: Contacting the original issuing organization directly to confirm credentials
Primary source verification requires contacting the organization that originally issued the credential — the medical school, licensing board, or certifying body — not a copy or intermediary.
Question 6: A provider's DEA registration is relevant in credentialing primarily because it confirms:
- Board certification status
- Authorization to prescribe controlled substances (Correct answer)
- Malpractice insurance coverage
- Hospital affiliation history
Correct answer: Authorization to prescribe controlled substances
A DEA registration authorizes a practitioner to prescribe, dispense, and administer controlled substances, making it a key credential for prescribing providers.
Question 7: Which of the following is an example of a 'red flag' that would typically trigger additional review during credentialing?
- A provider licensed in two states
- A gap in work history exceeding six months (Correct answer)
- Board certification in a primary specialty
- A malpractice policy with a $1M/$3M limit
Correct answer: A gap in work history exceeding six months
Unexplained gaps in work history of six months or more are standard red flags that require the provider to provide a written explanation before credentialing can proceed.
CPCS Basic 2
Which organization accredits managed care organizations and sets credentialing standards that many health plans follow?