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CPMSM Study Guide Material Latest 2025
What are four models of HMOs? - Staff Model Group Model Network Model Independent Practice Association (IPA) What are the four types of committees? - Standing Ad hoc Task force Continuous quality improvement team How many medical staff members comprise a Bylaws Committee? - 5 At least five active medical staff How many medical staff members comprise a Credentials Committee? - 5 At least five active medical staff How many medical staff members must serve on an Infection Control Committee? - 3 At least three active medical staff How many medical staff members must serve on a Medical Records Committee? - 1 At least one active medical staff How often should the Medical Records committee meet? - At least quarterly How many medical staff members must serve on a Pharmacy & Therapeutics Committee? - 5 At least five active medical staff How often should the Pharmacy & Therapeutics committee meet? - At least quarterly How many medical staff members must serve on a Utilization Review Committee? - 1
At least one active medical staff How often should the Utilization Review Committee meet? - Every other month
For TJC, does "privileges" refer to duties and prerogatives of each category or the clinical privileges to provide care? - Duties and prerogatives
Which accreditor requires an applicant to submit a statement that no health problems exist which could affect his or her ability to provide care? - TJC Which accreditor has no specific requirements for professional practice questions on the application or reapp? - DNV For Medicare deemed facilities, the delegation of credentialing agreement must include what clause? - Adhere to Medicare regulations How often must the delegate organization provide a report to Credentials for a URAC facility? - Annually What is the NCQA requirement for monitoring member complaints about providers? - Continually monitoring member complaints for all practitioner sites Performing a site visit within 60 days if a threshold was met What is the only NCQA-required reporting for delegated credentialing? - The names or files of practitioners or providers processed by the delegate What is the credentialing timeframe for URAC? - 6 months No credentialing application is submitted for initial review if it is signed and dated more than 180 days prior to credentialing committee review or if it contains primary or secondary source verification information collected more than six months prior to review. What are the two requirements for verification at reappointment for DNV? - Licensure Current Competence What is verification of a practitioner's credentials based upon evidence obtains by means other than direct contact with the issuing source of the credential? (e.g. copies of licenses/certifications or database queries) - Secondary Source What year was HIPAA established? - 1996 Which two entities can report to HIPDB? - Federal/state government agencies Health Plans Which agency was established to combat fraud and abuse in health insurance and health care delivery and to promote quality care by HIPAA? - HIPDB What year did reporting to HIPDB begin? - 1999
Federation of State Medical Boards What is the name of the source for demographic, educational, and practice information for all US physicians with MDs? - AMA Physician Masterfile What year was the AMA Master File started? - 1906 What is CIN-BAD? - Chiropractic Information Network - Board Action Databank What year was CIN-BAD started? - 1993 What is the CSA registration database? - Controlled Substances Act DEA Who maintains a database of individuals and entities excluded from federal programs including Medicare and Medicaid? - OIG Office of the Inspector General Who maintains the list of people and organizations excluded from doing business with the Federal Government? - SAM System for Award Management What is the former name of SAM? - EPLS Excluded parties list system What four systems are included in SAM? - CCR (Central Contractor Registry) Fedreg (Federal Agency Registration) ORCA - Online Representations and Certifications Applicaction EPLS - Excluded Parties List System In the managed care setting, how many levels of training must be verified? - Only the highest level (residency) or board certification What are the methods of verifying medical school if required? - Contact with the school Designated equivalent sources (AMA/AOA) ECFMG for foreign grads Which accreditation requires verification of only the highest level of education/training? - NCQA What type of verification of education can be provided directly by the provider to be accepted as PSV? - Transcript in Institution's sealed envelope with an unbroken institution seal. Organization must document that it opened envelope and viewed
the document.
What are the four occasions when licensure must be PSV for TJC? - Initial appointment Reappointment On expiration
Renewal/revision of privileges Are sanctions specifically addressed by DNV? - No What is the verification time limit on licensure for NCQA and URAC? - NCQA - 180 days URAC - 6 months How many years of licensure history for sanctions are required for URAC? - 5 What is special about the last digit of the DEA #? - It's a checksum of the other numbers in DEA What are the Medicare CoP requirements for verification of DEA? - None What is the verification time limit for DEA for NCQA? - None Must be current at time of credentialing. Does TJC have a requirement for verification of liability coverage? - None For practitioners with federal tort coverage, what is required for liability verification? - Copy of Federal Tort letter or Attestation from provider stating that they hold such coverage Do TJC, CoP or NCQA standards require criminal background checks? - No What year did the Civil Rights Act prohibit nondiscrimination? - 1871 How many peer recommendations are required by HFAP for initial appointment? - At least one How many peer recommendations are required by DNV for initial appointment? - At least two Which two accreditations do not have specific requirements for peer recommendations?
- NCQA, URAC What is the time limit for sanctions/exclusions for URAC? - 6 months Does TJC recommend or require that hospitals base evaluations for competence on the six general areas? - Recommend Is competence required to be verified prior to granting temporary privileges for DNV? - Yes
What is the time limit for attestations for NCQA? - 365 days 305 for CVO 180 for Medicare Deeming What is the time limit for attestations for URAC? - 180 days What does TJC call the process whereby the specific scope and content of patient care services are authorized for a healthcare practitioner by a healthcare organization, based on evaluation of the individual's credentials and performance? - privileging What are three methods of delineation of clinical privileges? - Laundry list Category/levels Core privileges For CoP, surgical privileges must be delineated for all practitioners performing surgery in accordance with... - the competencies of each practitioner What are CoP interpretive guidelines for timeline of review and updating of surgical privileges - At least every two years What does TJC require with regard to privilege delineation system? - Tailored to hospital Takes into account the hospital's technical and staff capability to support the procedures According to TJC, which three privileging events require NPDB query? - Initial Renewal New privilege request What is the max length of time that TJC allows for temporary/provisional credentialing? - 120 days What time limit does DNV state for locum tenens for temporary privileges? - six months What the maximum length of provisional credentialing for NCQA? - 60 days What does Medicare CoP state regarding allied health professionals and qualifications for medical staff membership? - Governing body determines which categories are eligible
What is HFAPs requirement regarding all AHPs who provide care? - Annual competence/skill assessment What is required by URAC for AHPs that provide clinical services? - A written agreement with the organization
Can NCQA credentials committee meetings and decision making be conducted only through email? - No What date does the NCQA use as the credentialing decision date? - When the designated medical director signs off on application
What is a unique requirement of the URAC credentialing committee? - At least one participating provider must not have any other role in the management of organization How often must URAC credentialing committee meet? - At least quarterly or as often as necessary Who is the ultimate authority in the hospital organization and legally responsible for everything that happens within the organization? - Governing body or board What do CoPs state about the composition of the executive committee? - Majority must be doctors of medicine or osteopathy Which four accreditation standards state that the governing body and the ultimate authority and responsibility for oversight and delivery of care - TJC, HFAP, DNV, AAAHC What types of applications does HFAP say qualify for expedited credentialing? - Applications that pose no problems including new graduates or physicians fully credentialed at a new hospital What five entities need to approve fast track credentialing for HFAP? - Department chair, credentials chair, MEC, CEO and governing body. Which accreditation requires documentation of delegation for expedited privileging? - URAC What is the process by which a professional review body considers whether a practitioner's clinical privileges or membership in a professional society will be adversely affected by a physician's competence or professional conduct. The foremost objective is the promotion of the highest quality of medical care as well as patient safety? - Peer review What is the continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality services or processes which achieve equity and improve the health of the community? - QA/PI Quality improvement What is defined as positive changes in capacity, process and outcomes of public health as practiced in government, private, and voluntary sector organizations? It involves strategic changes to address public health system weaknesses and the
and ongoing quality improvement efforts to ensure an agency achieves desired results.
- Performance Management What is an individual(s) with similar training, background or credential as the applicant?
- Peer (peer group) What is the evaluation or review of the performance of colleagues by professionals with similar types and degrees of clinical expertise? - Peer review What is the primary component of peer review? - To ensure that practitioners are rending acceptable and appropriate medical care Which organization started peer review and in what year? - American College of Surgeons Minimum Standard 1919 What type of review process is required by DNV at reappointment? - Must include a review of individual performance data for variation from benchmark. How many physicians are required to be involved in peer review for AAAHC? - At least two Who is responsible for peer review process under NCQA? - Credentialing committee QA/PI data must provide what kind of data? - Comparative data - not just numbers. LOS as compared to other same specialty providers Charges/reimbursements by procedure compared to others Sedation reversals for GI as compared to others with same procedure C-section rates compared to others Diagnosis related complications What is the name of the organization providing limited immunity from legal actions for physicians who enter into good faith review? It does not protect health care entities or physicians from being sued, nor prevent physicians from suing for reinstatement of their medical staff appointment. - HCQIA What year was the HCQIA founded? - 1986 What is the case holding that a medical center that alleged a defense of breach in
an employment contract in discharging a physician was ordered to answer interrogatories and produce documentation? - Century Medical Centers v Marin What case ruled that a physician suing the hospital for federal antitrust damages after it terminated his privileges was entitled to discovery of peer review records?
- Pagano v Oroville Hospital
