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 the significance of the Medicare Exclusions Database (OIG List of Excluded Individuals/Entities) in payor credentialing?
Answer: Providers on this list are excluded from participation in Medicare and Medicaid programs, making enrollment or continued network participation impermissible
Health plans must check the OIG exclusion list because enrolling excluded providers exposes the plan and organization to federal civil monetary penalties.
What is a 'site visit' in the context of NCQA health plan credentialing standards?
Answer: An on-site inspection of a provider's office to assess the physical environment, accessibility, and adequacy of the practice site
NCQA site visit standards require health plans (or their delegates) to conduct physical inspections of provider practice sites to verify practice quality and accessibility.
When a provider applies to join a health plan network and is denied, what right does the provider typically have under NCQA standards?
Answer: The right to be notified of the denial and, in most cases, the right to appeal or request reconsideration
NCQA standards require health plans to notify providers of adverse credentialing decisions and provide an opportunity for appeal or reconsideration.
What is the primary risk to a health plan that fails to properly oversee a credentialing delegation arrangement?
Answer: Loss of NCQA accreditation and potential liability for credentialing non-compliance affecting patient safety
Inadequate oversight of delegated credentialing can result in loss of NCQA accreditation and expose the health plan to compliance and liability risks.
What does 'roster management' mean in the context of payor credentialing?
Answer: The ongoing process of maintaining accurate, up-to-date lists of credentialed providers in a health plan's network directory
Roster management ensures that health plan provider directories and internal systems reflect current, accurate provider credentialing status and network participation.
Under the No Surprises Act, why has accurate provider network directory information (supported by credentialing data) become a critical compliance concern for health plans?
Answer: Inaccurate directories can lead to patients unknowingly receiving out-of-network care, triggering surprise billing protections and potential federal penalties for the plan
The No Surprises Act requires health plans to maintain accurate, up-to-date provider directories, and inaccurate listings can result in surprise billing violations and CMS penalties.