CPCS Data Management & Documentation Practices 3 — Questions and Answers
Question 1: A hospital's credentialing policy requires retention of closed provider files for 10 years. A department requests destruction of a file that is 8 years old. The specialist should:
- Approve destruction since most states require only 7 years
- Deny the request and retain the file until the 10-year threshold is met (Correct answer)
- Transfer the file to an off-site archive
- Consult with the provider before deciding
Correct answer: Deny the request and retain the file until the 10-year threshold is met
The organization's own policy sets a 10-year retention minimum and must be followed regardless of shorter state requirements.
Question 2: Which situation represents a breach of confidentiality in credentialing documentation practices?
- Sharing a provider's adverse action history with the NPDB as required by law
- Emailing a provider's peer reference letters to an unrelated department head (Correct answer)
- Disclosing malpractice history to the credentialing committee
- Providing verification of licensure to another hospital upon provider request
Correct answer: Emailing a provider's peer reference letters to an unrelated department head
Sharing confidential peer reference letters outside the credentialing committee without authorization violates confidentiality protections.
Question 3: A credentialing specialist notes that the same malpractice case appears twice in a provider's file with different claim amounts. The FIRST step is to:
- Report the discrepancy to risk management immediately
- Contact the malpractice carrier to obtain a verified claims history (Correct answer)
- Delete the lower-amount entry as likely erroneous
- Flag the file for legal review before any action
Correct answer: Contact the malpractice carrier to obtain a verified claims history
Primary source verification with the malpractice carrier will resolve which amount is accurate before any record is modified.
Question 4: An organization transitions from paper-based to electronic credentialing. Which risk should be addressed FIRST in the implementation plan?
- Training staff on the new user interface
- Establishing data conversion validation protocols (Correct answer)
- Purchasing additional server hardware
- Communicating the change to providers
Correct answer: Establishing data conversion validation protocols
Data conversion validation ensures historical records are accurately transferred to the electronic system before staff begins using it.
Question 5: The NCQA standards require that credentialing files be reviewed by a credentialing committee or physician within what timeframe after completion of verification?
- 30 days
- 60 days
- 90 days (Correct answer)
- 180 days
Correct answer: 90 days
NCQA requires credentialing decisions to be made within 180 days of application, with committee review typically expected within 90 days of completed verification.
Question 6: Which of the following is an example of a 'soft' credentialing data element that requires subjective documentation?
- State medical license number
- Peer reference assessment of clinical competence (Correct answer)
- NPI number
- DEA certificate expiration date
Correct answer: Peer reference assessment of clinical competence
Peer reference assessments involve subjective judgments about clinical competence rather than objective, verifiable facts.
Question 7: A provider submits an application with a 14-month gap in work history. Credentialing policy requires explanation of gaps exceeding 30 days. The specialist should:
- Approve the application if all licenses are current
- Request a written explanation from the provider before proceeding (Correct answer)
- Deny the application due to the unexplained gap
- Refer the file to the medical director without further inquiry
Correct answer: Request a written explanation from the provider before proceeding
Policy mandates that any gap over 30 days be explained, so a written explanation must be obtained from the provider before the file can move forward.
CPCS Data Management & Documentation Practices 3
A hospital's credentialing policy requires retention of closed provider files for 10 years.
A department requests destruction of a file that is 8 years old.
The specialist should: