CPCS Study Guide - Credentialing and Privileging Vocabulary

Vocabulary flashcards covering credentialing and privileging concepts from the CPCS study notes.

Credentialing

The process of obtaining, verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care in a hospital.

Privileging

The process of granting specific clinical privileges to a practitioner based on credentials, competence, and the hospital’s needs.

Primary Source Verification (PSV)

Verification of credentials directly from the issuing source (e.g., school, licensing board, training program).

Secondary Source Verification

Verification from sources other than the primary source when an PSV is not available; must be documented.

National Practitioner Data Bank (NPDB)

A national registry of adverse actions, licensure actions, and malpractice history used in credentialing; many actions must be reported or queried.

Focused Professional Practice Evaluation (FPPE)

An initial, time-limited evaluation of a practitioner’s performance for a new privilege or concern.

Ongoing Professional Practice Evaluation (OPPE)

Continuous monitoring of a practitioner’s performance between reappointments.

Recredentialing

The process of reassessing a practitioner’s credentials and current competence to renew membership or privileges.

Attestation

A signed statement that information on the application is true, complete, and current (including health status).

Bylaws

Governing documents that define membership criteria, governance, and the organization’s structure for the medical staff.

Policies and Procedures

Formal guidelines detailing how credentialing and related processes are carried out.

Governing Body

The hospital board or equivalent authority that approves policies, credentials, and privileges.

Medical Staff

The group of licensed clinicians and allied professionals authorized to provide patient care in a hospital.

Licensure

A state-issued license to practice medicine or other professions.

Board Certification

Certification by ABMS or AOA indicating specialty expertise; verification is commonly required.

Licensed Independent Practitioner (LIP)

An individual legally permitted to provide patient care independently, within license scope and granted privileges.

Non-physician Practitioner (NPP) / Advanced Practice Professional (APP)

APRs, PAs, CNMs, etc., who may be credentialed and privileged to provide care under state law.

Medicare Conditions of Participation (CoPs)

Federal requirements hospitals must meet to participate in Medicare and related programs.

Deemed Status

CMS recognition that an accrediting organization’s standards meet CMS requirements for participation.

Credential Verification Organization (CVO)

An organization that conducts credentialing verifications (PSV, etc.) for another organization.

Provider Panel

A group of providers contracted with a health plan or MCO to deliver care to members.

Telemedicine Privileges

Privileges to provide care remotely; may rely on distant-site credentialing with conditions for alignment.

Red Flags (Credentialing)**

Discrepancies or concerning items (gaps, inconsistent data, licensure issues) flagged during verification.

Core Privileges

The essential set of privileges typically granted to a practitioner in a specialty.

Privilege Delineation

Document listing the specific clinical privileges granted to each practitioner.

Peer Recommendations

Input from peers about an applicant’s competence, professionalism, and current performance.

Credentialing Committee

Committee that reviews applications and makes recommendations on membership and privileges.

Credentialing File

The compilation of verification documents and information used to make credentialing decisions.

Expedited Credentialing

Fast-track credentialing for applicants meeting specific criteria, with full verification often still required.

Provisional Credentialing

Temporary credentialing status for new or interim participation before full credentialing is complete.

Temporary Privileges

Time-limited privileges granted during emergencies or transitional periods.

Disaster Privileges

Temporary, time-limited privileges granted to volunteers or staff during a disaster or surge.

Redirection of Verification (Designated Equivalent Source)

A pre-approved secondary source that is considered equivalent to PSV when the primary source is unavailable.

OCQ/OPPE/FPPE Relationship

Ongoing evaluation and data collection tied to quality and performance improvement.

Nondiscrimination

Credentialing decisions must not be based on race, gender, religion, etc.; must reflect competency.

Attestation Statement

A formal statement within the application attesting to truthfulness and accuracy of information.

Provider Directories

Directories listing credentialed practitioners for patients, payers, and networks; must align with credentialing data.

Data Banks (FSMB/ABMS/FMOs)

Generated profiles from FSMB, ABMS, and related bodies used for verification and sanctions checks.

OIG/SAM Exclusions

Federal exclusions databases checked for sanctions; crucial for eligibility to participate.

Residency Verification

PSV of residency training programs to confirm education and training completed.

Release of Information / Consent

Formal consent allowing verification and disclosure of credentialing information.

Governing Body Authority over Privileges

Governing body grants, revises, or revokes privileges based on medical staff recommendations.

Ongoing Monitoring must include

Sanctions, complaints, and adverse information monitored between credentialing cycles.

Sanctions & Exclusions

Actions by licensure boards, NPDB, OIG, and CMS that can affect credentialing decisions.

Surgical Privileges Rosters

Official rosters listing surgical privileges granted to each practitioner, reviewed periodically.