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 payor credentialing in the context of healthcare provider enrollment?
Answer: The process by which a health plan verifies a provider's qualifications before allowing them to participate in the plan's network
Payor credentialing is the health plan's process of verifying provider credentials to establish network participation and enable claims reimbursement.
What is credentialing delegation in managed care?
Answer: A formal arrangement where a health plan authorizes an organization (e.g., a hospital or medical group) to perform credentialing functions on the plan's behalf
Credentialing delegation allows a health plan to formally authorize an external entity to conduct credentialing activities, subject to oversight and audit.
Which accreditation body sets widely recognized standards for health plan credentialing delegation programs?
Answer: NCQA (National Committee for Quality Assurance)
NCQA's health plan accreditation standards are the most widely referenced framework for managed care credentialing and delegation requirements in the U.S.
Under NCQA delegation standards, how often must a health plan conduct an audit of a delegated credentialing entity?
Answer: At least annually
NCQA requires health plans to audit delegated credentialing organizations at least annually to ensure compliance with delegation agreement requirements.
What must a delegation agreement between a health plan and a delegated entity include?
Answer: Scope of delegated functions, performance standards, audit rights, and remedies for non-compliance
A delegation agreement must define the scope of delegated activities, set performance expectations, grant audit rights, and specify corrective action for non-compliance.
What is the typical timeframe that health plans (and NCQA standards) allow for completing initial credentialing of a provider after receipt of a complete application?
Answer: 180 days
NCQA standards generally allow up to 180 days to complete initial credentialing from receipt of a complete application.