CPCS Provider Enrollment and Payer Credentialing Processes 2 — Questions and Answers
Question 1: A provider submits an enrollment application to Medicare and receives a 'development letter.' What does this mean?
- The application has been approved pending a site visit
- Additional information or documentation is needed to process the application (Correct answer)
- The provider has been rejected and must reapply
- The application has been forwarded to a state Medicaid agency
Correct answer: Additional information or documentation is needed to process the application
A development letter from a Medicare contractor indicates the application is incomplete and specific additional information or supporting documents are required.
Question 2: Which National Provider Identifier (NPI) type should a solo practitioner use when billing independently?
- Type 2 NPI as a subpart of a group
- Type 1 NPI as an individual provider (Correct answer)
- Type 3 NPI as a specialty-specific identifier
- Either Type 1 or Type 2 at the provider's discretion
Correct answer: Type 1 NPI as an individual provider
Type 1 NPIs are assigned to individual health care providers, including solo practitioners billing under their own name.
Question 3: A hospital-based physician group wants to enroll with a commercial payer. Which document typically outlines the contractual terms including fee schedules?
- Provider Participation Agreement (Correct answer)
- Certificate of Insurance
- CAQH attestation form
- CMS-855I application
Correct answer: Provider Participation Agreement
The Provider Participation Agreement (also called a provider contract) outlines the terms and conditions, including reimbursement rates and fee schedules, between a provider and a payer.
Question 4: Under the Medicare enrollment process, what is the purpose of the CMS-855B application?
- Enrollment of individual physicians and non-physician practitioners
- Enrollment of clinics, group practices, and certain other suppliers (Correct answer)
- Enrollment of durable medical equipment suppliers
- Reassignment of Medicare billing to another entity
Correct answer: Enrollment of clinics, group practices, and certain other suppliers
The CMS-855B is used to enroll clinics, group practices, and certain other suppliers that are not individuals into the Medicare program.
Question 5: A credentialing specialist discovers a provider's DEA registration has expired. What is the most appropriate immediate action?
- Notify the provider and place their privileges on hold until renewal is confirmed (Correct answer)
- Submit the credentialing file with a note that renewal is pending
- Remove the provider from the medical staff roster permanently
- File a complaint with the state medical board
Correct answer: Notify the provider and place their privileges on hold until renewal is confirmed
An expired DEA registration is a patient safety and legal compliance issue requiring immediate notification to the provider and temporary hold on prescribing privileges until renewal is verified.
Question 6: What is 'payer mix' in the context of provider enrollment strategy?
- The combination of different insurance plans a provider accepts (Correct answer)
- The ratio of in-network to out-of-network claims submitted
- The average reimbursement rate across all contracted payers
- The number of payers a credentialing specialist manages simultaneously
Correct answer: The combination of different insurance plans a provider accepts
Payer mix refers to the distribution of different insurance plans (Medicare, Medicaid, commercial, self-pay, etc.) that a provider or practice accepts and from which they receive payment.
Question 7: Which federal program requires providers to enroll before ordering or referring certain items and services for beneficiaries?
- TRICARE
- Medicare (Correct answer)
- CHIP
- FEHB
Correct answer: Medicare
Medicare requires ordering and referring providers to be enrolled in or validly opted out of Medicare before their orders and referrals for Medicare-covered items and services will be accepted.
CPCS Provider Enrollment and Payer Credentialing Processes 2
A provider submits an enrollment application to Medicare and receives a 'development letter.' What does this mean?