CPCS CPCS - Certified Provider Credentialing Specialist Payor Credentialing and Delegation Questions and Answers 2

Question 1

What is a Council for Affordable Quality Healthcare (CAQH) ProView used for in payor credentialing?

Accepted Answer

A centralized online repository where providers store credentialing data that can be shared with multiple health plans simultaneously

Answer

A federal database for reporting adverse actions against providers

Answer

A billing and claims processing platform used by CMS

Answer

A state licensing board verification portal

Question 2

What does 'provider enrollment' mean in the context of payor credentialing?

Accepted Answer

The administrative process of registering a credentialed provider in a health plan's system so they can bill and receive reimbursement

Answer

The initial clinical privileges application at a hospital

Answer

The registration of a provider with the state medical board

Answer

The process of enrolling a provider in continuing medical education

Question 3

If a health plan decides to terminate a delegated credentialing agreement, what is the primary consequence for providers credentialed under that agreement?

Accepted Answer

The health plan assumes direct responsibility for credentialing those providers and must re-credential them under its own standards

Answer

All providers are automatically disenrolled from the network

Answer

The providers must reapply to the state licensing board

Answer

The National Practitioner Data Bank is notified of the termination

Question 4

What is re-credentialing (re-attestation) in managed care, and how often is it typically required?

Accepted Answer

The periodic re-verification of a provider's credentials by a health plan, typically every three years

Answer

The annual renewal of a provider's clinical privileges at a hospital

Answer

The monthly verification of a provider's DEA registration

Answer

The one-time verification required when a provider joins a new specialty

Question 5

What is the purpose of a 'clean claim' requirement in the context of provider enrollment?

Accepted Answer

Ensuring a provider is fully enrolled and their billing information is accurate so that claims submitted are processed without rejection or delay

Answer

Verifying that a provider has no malpractice claims on file

Answer

Confirming that a provider's DEA license is free of restrictions

Answer

Checking that a provider's application contains no missing documents

Question 6

Under NCQA standards, which of the following must be verified directly from the primary source during health plan credentialing?

Accepted Answer

State licensure status and DEA registration

Answer

Only the provider's curriculum vitae

Answer

Only the malpractice insurance certificate provided by the provider

Answer

The provider's self-reported work history without independent verification