Data Management & Documentation Practices 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 Data Management & Documentation Practices flashcards as text
A hospital's credentialing policy requires retention of closed provider files for 10 years. A department requests destruction of a file that is 8 years old. The specialist should:
Answer: Deny the request and retain the file until the 10-year threshold is met
The organization's own policy sets a 10-year retention minimum and must be followed regardless of shorter state requirements.
Which situation represents a breach of confidentiality in credentialing documentation practices?
Answer: Emailing a provider's peer reference letters to an unrelated department head
Sharing confidential peer reference letters outside the credentialing committee without authorization violates confidentiality protections.
A credentialing specialist notes that the same malpractice case appears twice in a provider's file with different claim amounts. The FIRST step is to:
Answer: Contact the malpractice carrier to obtain a verified claims history
Primary source verification with the malpractice carrier will resolve which amount is accurate before any record is modified.
An organization transitions from paper-based to electronic credentialing. Which risk should be addressed FIRST in the implementation plan?
Answer: Establishing data conversion validation protocols
Data conversion validation ensures historical records are accurately transferred to the electronic system before staff begins using it.
The NCQA standards require that credentialing files be reviewed by a credentialing committee or physician within what timeframe after completion of verification?
Answer: 90 days
NCQA requires credentialing decisions to be made within 180 days of application, with committee review typically expected within 90 days of completed verification.
Which of the following is an example of a 'soft' credentialing data element that requires subjective documentation?
Answer: Peer reference assessment of clinical competence
Peer reference assessments involve subjective judgments about clinical competence rather than objective, verifiable facts.
A provider submits an application with a 14-month gap in work history. Credentialing policy requires explanation of gaps exceeding 30 days. The specialist should:
Answer: Request a written explanation from the provider before proceeding
Policy mandates that any gap over 30 days be explained, so a written explanation must be obtained from the provider before the file can move forward.