NAMSS CPCS Participation Guide
Hospital Credentialing Driven by: - ANS -- Federal/State Regulations
- CMS
- Hospital CoPs
- HCQIA
- Accreditation Standards
- TJC
- HFAP
- DNV
-Bylaws, Rules and Regs
-Standard of Care (legal aspect)
Managed Care Org Credentialing Driven by: - ANS --Federal/State Regulations
-Policies and Procedures
-Accreditation Standards (NCQA, URAC)
-Standard of Care (legal aspect)
-HEDIS/CAHPS
MCO Organization Chart - ANS -Director of Managed Care
Contracts Management --> Client Services
Financial Management --->Network Administration
CVO Organizational Chart - ANS -(depending on size)
Director ---> Contract sales/Credentialing Staff/Human Resources
CVO Credentialing Driven by: - ANS -- Contract
- Accredidation Standards (NCQA, URAC,TJC,AAAHC, CMS, HFAP & DNV)
-Policies and Procedures
Ambulatory Care/Medical Office/Surgical Center Credentialing Driven by: - ANS -- Accreditation
Standards (AAAHC, TJC, NCQA)
- CMS Regulations
- State law
- Policies and Procedures
- Contractual Agreements
What is hospital credentialing driven by? - ANS -- Federal/State Regulations
- CMS
- Hospital CoPs
, - HCQIA
- Accreditation Standards
- TJC
- HFAP
- DNV
-Bylaws, Rules and Regs
-Standard of Care (legal aspect)
Difference between an Independant CVO vs. Organization CVO? - ANS -Independant CVO
contracts with many outside organizations. Typically for-profit company.
Organization CVO handles org specific credentialing; part of the not-for-profit org. May be
for-profit and have customers outside of the org.
Which entity or entities have their credentialing influenced by CONTRACTUAL AGREEMENTS
and ACCREDITATION STANDARDS composed of AAAHC, TJC, and NCQA? - ANS
-Ambulatory Care, Medical office/Surgical Center
Application Process - ANS -*Timeframe to process a complete application is defined in:
Bylaws (hospital)
Policies and Procedures (MCO and CVO)
*Application must be complete
*PSV must be complete
*Current competency for privileges requested is obtained
Hosptial Application Process - ANS -*TJC only requires MEC; Not Credential Committee
1. App received
2. Verify complete & all requested materials included
3. Process app; conduct PSV & verify current competency for privileges requested
4. Chief of service/dept review and reccomendation
5. Executive Committee Review and reccomend to Board
6. Board approval
7. Notifiy applicant of final decision (within timeframe specified in MS bylaws, denial;app must
be told reason for denial)
(TJC Communication)
Then, notify facility of new applicants and key personnel should have access to approved
privileges (scope of practice)
MCO: NCQA Application Process - ANS -1. App received
2. verify complete & all req materials included
3. Process app & conduct PSV
Hospital Credentialing Driven by: - ANS -- Federal/State Regulations
- CMS
- Hospital CoPs
- HCQIA
- Accreditation Standards
- TJC
- HFAP
- DNV
-Bylaws, Rules and Regs
-Standard of Care (legal aspect)
Managed Care Org Credentialing Driven by: - ANS --Federal/State Regulations
-Policies and Procedures
-Accreditation Standards (NCQA, URAC)
-Standard of Care (legal aspect)
-HEDIS/CAHPS
MCO Organization Chart - ANS -Director of Managed Care
Contracts Management --> Client Services
Financial Management --->Network Administration
CVO Organizational Chart - ANS -(depending on size)
Director ---> Contract sales/Credentialing Staff/Human Resources
CVO Credentialing Driven by: - ANS -- Contract
- Accredidation Standards (NCQA, URAC,TJC,AAAHC, CMS, HFAP & DNV)
-Policies and Procedures
Ambulatory Care/Medical Office/Surgical Center Credentialing Driven by: - ANS -- Accreditation
Standards (AAAHC, TJC, NCQA)
- CMS Regulations
- State law
- Policies and Procedures
- Contractual Agreements
What is hospital credentialing driven by? - ANS -- Federal/State Regulations
- CMS
- Hospital CoPs
, - HCQIA
- Accreditation Standards
- TJC
- HFAP
- DNV
-Bylaws, Rules and Regs
-Standard of Care (legal aspect)
Difference between an Independant CVO vs. Organization CVO? - ANS -Independant CVO
contracts with many outside organizations. Typically for-profit company.
Organization CVO handles org specific credentialing; part of the not-for-profit org. May be
for-profit and have customers outside of the org.
Which entity or entities have their credentialing influenced by CONTRACTUAL AGREEMENTS
and ACCREDITATION STANDARDS composed of AAAHC, TJC, and NCQA? - ANS
-Ambulatory Care, Medical office/Surgical Center
Application Process - ANS -*Timeframe to process a complete application is defined in:
Bylaws (hospital)
Policies and Procedures (MCO and CVO)
*Application must be complete
*PSV must be complete
*Current competency for privileges requested is obtained
Hosptial Application Process - ANS -*TJC only requires MEC; Not Credential Committee
1. App received
2. Verify complete & all requested materials included
3. Process app; conduct PSV & verify current competency for privileges requested
4. Chief of service/dept review and reccomendation
5. Executive Committee Review and reccomend to Board
6. Board approval
7. Notifiy applicant of final decision (within timeframe specified in MS bylaws, denial;app must
be told reason for denial)
(TJC Communication)
Then, notify facility of new applicants and key personnel should have access to approved
privileges (scope of practice)
MCO: NCQA Application Process - ANS -1. App received
2. verify complete & all req materials included
3. Process app & conduct PSV
