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§16-1A-3. Definitions.

For the purposes of this article, the following definitions apply:

(a) "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.

(b) "Credentialing entity" means any health care facility, as that term is defined in subsection (j), section two, article two-d of this chapter, or payor or network that requires credentialing of health care practitioners.

(c) "Credentialing Verification Organization" means an entity that performs primary source verification of a health care practitioner's training, education, experience; "statewide credentialing verification organization" means the credentialing verification organization selected pursuant to the provisions of section five of this article.

(d) "Health care practitioner" or "practitioner" means a person required to be credentialed using the uniform forms set forth in the rule promulgated pursuant to the authority granted in section two, article one-a of this chapter.

(e) "Insurance Commissioner" or "Commissioner" means the Insurance Commissioner of the State of West Virginia as set forth in article two, chapter thirty-three of this code.

(f) "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 programs for hospitals and other health care organizations.

(g) "National Committee for Quality Assurance" or "NCQA" is a private, 501(c)(3) not-for-profit organization that evaluates and certifies credentialing verification organizations.

(h) "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.

(i) "Payor" means a third party administrator as defined in section two, article forty-six , chapter thirty-three of this code and including third party administrators that are required to be registered pursuant to section thirteen, article forty-six, chapter thirty-three of this code, any insurance company, health maintenance organization, health care corporation or any other entity required to be licensed under chapter thirty-three of this code and 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.

(j) "Primary source verification procedure" means the procedure used by a credentialing verification organization to, in accordance with 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.

(k) "Secretary" means the Secretary of the West Virginia Department of Health and Human Resources as set forth in chapter sixteen, article one of this code.

(l) "Uniform application form" or "uniform form" means the blank uniform credentialing or recredentialing form developed and set forth in a joint procedural rule promulgated pursuant to section two of this article.

Note: WV Code updated with legislation passed through the 2017 Regular Session
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