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
Under CMS Conditions of Participation, which practitioner category is explicitly required to be credentialed and privileged by the hospital medical staff?
Answer: All licensed independent practitioners (LIPs) who provide patient care
CMS requires that all licensed independent practitioners who are permitted to provide patient care services within the hospital undergo credentialing and privileging.
A provider requests privileges for a newly FDA-approved procedure that the hospital has never offered. What is the accreditation-compliant first step?
Answer: Develop criteria for the new privilege before considering any individual application
Accreditation standards require that privilege criteria be established at the institutional level before evaluating any individual's qualifications for new procedures.
Which scenario correctly describes a situation requiring mandatory NPDB reporting by a hospital?
Answer: A physician's clinical privileges are reduced for more than 30 days following a professional review action
Hospitals must report to the NPDB when a practitioner's clinical privileges are reduced, restricted, or revoked for more than 30 days following a professional review action.
What is the accreditation significance of verifying a provider's work history for the past five to ten years during credentialing?
Answer: It helps identify any unexplained gaps that may indicate disciplinary issues or performance concerns
Reviewing work history helps uncover unexplained gaps that may signal disciplinary actions, substance abuse treatment, or other concerns requiring further inquiry.
Under NCQA standards, what is the maximum time allowed between a practitioner's recredentialing decisions to maintain continuous network participation?
Answer: 24 months
NCQA requires health plans to recredential network practitioners at least every 24 months (two years) to maintain their active participation status.
A credentialing specialist receives a primary source verification response indicating a provider's license is 'under investigation.' What is the appropriate compliance action?
Answer: Place the application on hold and notify the credentials committee of the finding
An active license investigation is a material adverse finding that must be disclosed to and reviewed by the credentials committee before any credentialing decision.
Which accreditation standard concept allows a health plan to rely on another accredited organization's credentialing without duplicating the full process?
Answer: Delegated credentialing
Delegated credentialing allows a health plan to formally transfer credentialing responsibilities to another organization, subject to ongoing oversight and audit requirements.