Certification

CPCS Test Content Outline

The CPCS exam addresses the following content. Candidates are required to demonstrate proficiency by answering exam questions that evaluate their knowledge of facts, concepts and processes required to complete the tasks described below.

Accreditation Compliance (14%)

1. Perform ongoing audits so that all information meets internal and accrediting standards for accuracy and completeness.

2. Ensure that license, DEA and board certification are current at all times by monitoring and documenting renewals in compliance with internal processes, regulatory bodies, and accreditation standards.

3. Track provisional status date and complete evaluation process in compliance with internal procedures and accreditation standards.

4. Accurately respond to requests for practitioner information in accordance with internal procedures.

5. Ensure an accurate practitioner directory containing verified education, training, and board certification.

6. Manage and archive files according to organizational procedures and accreditation standards.

7. Conduct audits of delegated credentialing entities to confirm that all delegates are compliant with specific delegation arrangements and established standards by NCQA and/or internal organizational policies and procedures.

8. Explain process and timelines to new applicants.

Initial Application/Reapplication Process (42%)

1. Process an application to completeness as determined by state, federal or accrediting agency guidelines and standards for review, recommendations and decision by the appropriate organizational committee or body.

2. Manage the reappointment/recredentialing process in accordance with applicable standards.

3. Verify applicant’s eligibility for membership/participation according to established membership criteria.

4. Obtain and maintain Medicare attestation statements in compliance with CMS regulations.

5. Ensure that attestation from an applicant is provided within the acceptable timeframe. Review attestation signature and date to ensure compliance with accreditation standards.

6. Review applications and identify time gaps that deviate from organization standards.

7. Request and document information to explain the reason for any identified time gaps.

8. Obtain acceptable equivalent source verification for medical school, residency or board certification in compliance with internal credentialing procedures and accreditation standards.

9. Compare scope of practice to privileges requested according to established guidelines and process for review and approval in compliance with internal policies.

10. Obtain and review CME in accordance with standards, regulations and departmental and organization policies and procedures.

11. Obtain information to verify current competency according to regulatory and accreditation standards and departmental procedures.

12. Perform a final review of a file to ensure compliance with internal credentialing procedures.

13. Identify timeframes of time-sensitive information so that all times are in compliance with regulatory and/or accrediting bodies.

14. Send notification of practitioner approval to appropriate internal departments in compliance with internal policies and procedures.

15. Obtain acceptable verification of medical education and training according to regulatory and accreditation standards and departmental procedures.

16. Verify that a site survey has been completed in compliance with NCQA and organizational standards.

Primary Source Verification (38%)

1. Request and process information from primary sources in accordance with accreditation standards and internal credentialing procedures.

2. Verify practitioner licensure and DEA registration so that primary source verification results are received, documented and maintained.

3. Verify board certification from acceptable verification sources in compliance with accreditation bodies and organizational policies and procedures.

4. Query the NPDB and/or HIPDB so complete reports for all queried practitioners are retrieved, printed and reviewed in compliance with regulatory and/or accrediting body requirements.

5. Check Medicare or Medicaid exclusions, sanctions and reinstatements in compliance with internal procedures and regulatory and accreditation requirements.

6. Obtain malpractice claims coverage history from appropriate sources in compliance with internal procedures and state, federal and accreditation standards.

7. Submit queries for criminal background checks in accordance with organizational and regulatory/accreditation standards.

8. Query the ECFMG to verify foreign medical graduate status.

9. Obtain and analyze work history from entities in compliance with accreditation standards.

10. Verify hospital affiliations in accordance with internal credentialing procedures and accreditation standards.

11. Obtain peer reference information in compliance with regulatory/accreditation standards and organizational procedures.

12. Initiate an investigation process for adverse information in compliance with internal credentialing procedures.

13. Complete a peer review profile for reappointment in compliance with departmental and organizational policies and procedures, and accreditation and regulatory requirements.

Privileging (6%)

1. Process requests for additional privileges in compliance with accreditation standards, regulatory agencies and organizational requirements.

2. Distribute practitioner clinical privileges to all appropriate recipients as defined by the organization in compliance with JCAHO requirements.

3. Process a request for temporary privileges, review and obtain approval by the appropriate organizational persons so that all organizational, accrediting body and regulatory requirements are met.