CPCS - Certified Provider Credentialing Specialist Payor Credentialing and Delegation Questions and Answers Flashcards
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Read the first 6 CPCS - Certified Provider Credentialing Specialist Payor Credentialing and Delegation Questions and Answers flashcards as text
What is a Council for Affordable Quality Healthcare (CAQH) ProView used for in payor credentialing?
Answer: A centralized online repository where providers store credentialing data that can be shared with multiple health plans simultaneously
CAQH ProView allows providers to enter their credentialing data once and authorize multiple health plans to access it, reducing redundant paperwork.
What does 'provider enrollment' mean in the context of payor credentialing?
Answer: The administrative process of registering a credentialed provider in a health plan's system so they can bill and receive reimbursement
Provider enrollment is the billing-focused step that follows credentialing, linking the provider to the health plan's claims system with a provider number.
If a health plan decides to terminate a delegated credentialing agreement, what is the primary consequence for providers credentialed under that agreement?
Answer: The health plan assumes direct responsibility for credentialing those providers and must re-credential them under its own standards
When a delegation agreement is terminated, the health plan takes back direct credentialing responsibility and must ensure providers meet its own credentialing standards.
What is re-credentialing (re-attestation) in managed care, and how often is it typically required?
Answer: The periodic re-verification of a provider's credentials by a health plan, typically every three years
Re-credentialing in managed care involves re-verifying provider credentials at defined intervals, with NCQA and most plans requiring re-credentialing every three years.
What is the purpose of a 'clean claim' requirement in the context of provider enrollment?
Answer: Ensuring a provider is fully enrolled and their billing information is accurate so that claims submitted are processed without rejection or delay
A clean claim requires complete and accurate provider enrollment data so that claims route correctly to the right provider record and are paid without delay.
Under NCQA standards, which of the following must be verified directly from the primary source during health plan credentialing?
Answer: State licensure status and DEA registration
NCQA requires primary source verification of state licensure and DEA registration, among other elements, directly from the issuing authority.