Accreditation Standards and Compliance Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Accreditation Standards and Compliance flashcards as text
A credentialing specialist discovers that a provider's malpractice insurance has lapsed mid-credentialing cycle. What is the compliance-required immediate action?
Answer: Notify the credentials committee and suspend privileges pending proof of coverage
Active malpractice coverage is a continuous credentialing requirement; lapsed coverage requires immediate notification to the committee and suspension of privileges.
Under NCQA standards, which body is ultimately responsible for approving or denying credentials for practitioners in a health plan network?
Answer: The credentials committee or delegated credentialing entity
NCQA requires that a credentials committee or properly delegated entity—not an individual—make final credentialing decisions.
What must a hospital do when it identifies a potential patient safety issue through the OPPE process for a credentialed provider?
Answer: Initiate an FPPE to investigate the specific concern
OPPE findings that raise safety concerns trigger an FPPE to conduct a focused, time-limited investigation before any privilege action.
Which accreditation standard governs how an organization must handle a provider's request for a hearing following an adverse credentialing action?
Answer: Health Care Quality Improvement Act (HCQIA) fair hearing requirements
HCQIA establishes the fair hearing and appeals process that hospitals must follow when taking adverse professional review actions against practitioners.
A delegated credentialing organization fails a NCQA delegation audit. What is the health plan's required response?
Answer: Conduct an oversight audit and develop a corrective action plan with the delegate
NCQA requires the health plan to conduct oversight, document deficiencies, and work with the delegate on a corrective action plan when audit failures occur.
Which document serves as the primary governance instrument establishing the structure and authority of a hospital medical staff credentialing process?
Answer: The medical staff bylaws
Medical staff bylaws are the foundational governance document that establishes the authority, structure, and processes governing credentialing and privileging.
When an accreditation surveyor reviews credentialing files, which finding would most likely result in a Requirement for Improvement (RFI) under TJC standards?
Answer: Missing written confirmation of primary source verification for a provider's medical degree
Absent documentation of primary source verification for required credentials like a medical degree is a direct standards violation resulting in an RFI.