CMOM Module 5
Credentialing - correct answer ✔verifies that a physician meets standards
through the review of license, experience, certification, education, training,
malpractice and adverse clinical occurrences, clinical judgement and
character via investigation and observation
Privileging - correct answer ✔Defines a physician's scope of practice and the
clinical services he or she may provide
Council for Affordable Quality HealthCare (CAQH) - correct answer ✔not-for-
profit collaborative alliance of health plans and networks which offers a
standardized credentialing process
PECOS (Provider Enrollment, Chain and Ownership System) - correct
answer ✔Medicare's Internet Based provider enrollment
NCQ (National Committee for Quality Assurance) - correct answer ✔used to
limit its accreditation to HMOs, but has recently expanded to accredit CVOs,
Behavioral Managed Health Care organizations and Physician Organizations
JCAHO (Joint Commission on Accreditation of Healthcare Organizations -
correct answer ✔started out as a hospital accreditation org, accredits all
types of MCOs through its health care network accreditation program. They
Also have a specific set of standards for PPOs and Managed Behavioral
Health Care Orgs
AAHCC (American Accreditation HealthCare Commission) - correct answer
✔only accredits orgs that specialize in carry out utilization reviews. They have
recently broadened their focus to accredit MCOs.
, MQC (Medical Quality Commission) - correct answer ✔The smallest
accreditation group, accredits medical groups and Independent Practice
Associations (IPAs)
Exclusive Managed Indemnity - correct answer ✔In this type of plan, patient
is free to go to any provider, but plan requires some pre-certification by the
payer for inpatient stays and some outpatient procedures
PHO (Physician Hospital Organization) - correct answer ✔Tied to a specific
hospital, negotiates with the Managed Care organization (MCO) for integrated
or affiliated services with the hospital
PPO (Preferred Provider Organization) - correct answer ✔providers are
contract providers and maintained in a network listing provided to
beneficiaries. They may self refer and see any specialist as long as they stay
within the network.
Silent PPO - correct answer ✔A plan that has two ways to access your
contracted discount fee plan.
HMO (Health Maintenance Organization) - correct answer ✔Contract that
typically uses a captitated form of reimbursement and limits the ability of a
patient to see a specialist without a referral from a PCP as a means to control
costs
Group Model (HMO) - correct answer ✔consists of private practice
physicians and other providers, including hospitals, working under contract
with the HMO, accepting discount FFS or capitation Per Member Per Month
(PMPM). Usually a PCP, 'gatekeeper', and patient cannot see a specialist
without referral from the gatekeeper.
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