W. Va. Code R. § 64-89B-2 - Definitions
2.1. "Commissioner "
means the West Virginia Insurance Commissioner .
2.2. "Completed and Clean Credentialing
Application " means an application that is completed in its entirety, including
all required supporting documents and signatures.
2.3. "Credentialing " means the process used
to assess and validate the qualifications of a health care practitioner,
including, but not limited to, an evaluation of licensure status, education,
training, experience, competence and professional judgment.
2.4. "Credentialing entity" means any health
care facility, payor or network that requires credentialing of health care
practitioners; "credentialing entity" has the same meaning ascribed to "health
care entity" in W. Va. Code of St. Rules 64, 114CSR3.4.
2.5. "Credentialing Verification
Organization" or "CVO" means an entity that performs primary source
verification of a health care practitioner's training, education and
experience.
2.6. "Health Care
Practitioner " or "practitioner" means a health care provider who is licensed,
certified, or otherwise authorized to provide health care services, as
designated by the Secretary and Commissioner to be subject to the uniform
credentialing and recredentialing forms.
2.7. "Joint Commission," formerly known as
the Joint Commission on Accreditation of Healthcare Organizations or "JCAHO ,"
is a private sector, United States-based, not-for-profit organization that
operates voluntary accreditation for hospitals and other health care
organizations.
2.8. "National
Committee for Quality Assurance " or "NCQA" is a private, 501(c)(3)
not-for-profit organization that evaluates and certifies credentialing
verification organizations.
2.9.
"Network " means an organization that represents or contracts with a defined set
of health care practitioners under contract to provide health care services to
a payor's enrollees.
2.10. "Payor "
means any entity required to be licensed by the Commissioner that, in return
for premiums paid by or on behalf of enrollees, indemnifies such enrollees or
reimburses health care practitioners for medical or other services provided to
enrollees by health care practitioners; payor includes third-party
administrators required to be licensed by or registered with the
Commissioner .
2.11. "Primary source
verification procedure " means the procedure used by a CVO to, in accordance
with the National Committee for Quality Assurance standards, collect, verify
and maintain the accuracy of documents and other credentialing information
submitted in connection with a health care practitioner's application to be
credentialed.
2.12. "Request for
Proposals " or "RFP" means that step in the state purchasing process in which a
state agency requests that vendors submit bids to perform services or deliver
goods.
2.13. "Secretary " means the
Secretary of the West Virginia Department of Health and Human
Resources.
2.14. "Statewide
credentialing verification organization" means the credentialing verification
organization selected pursuant to the provisions of W. Va. Code §
16-1A-5
and this rule.
2.15. "Uniform
Credentialing Committee" or "UCC" means the advisory group established pursuant
to W. Va. Code §
16-1A-4.
2.16. "Verification Profile " means a document
or electronic file that contains practitioner -specific information requested by
a credentialing entity.
Notes
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