W. Va. Code R. § 64-89B-2

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 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.

W. Va. Code R. § 64-89B-2