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§33-25C-2. Definitions.

For purposes of this article:

(a) "Commissioner" means the commissioner of insurance.

(b) "Credentials" means medical training, education, specialties, and board certifications of the provider.

(c) "Enrollee" is a natural person who has entered into an agreement with a health maintenance organization or prepaid limited health service organization for the provision of managed health care.

(d) "External review" means a process, independent of all affected parties, to determine if a health care service is medically necessary, or experimental.

(e) "Health care plan" means a plan that establishes, operates, or maintains a network of health care providers that have entered into agreements with the plan to provide health care services to enrollees to whom the plan has the ultimate obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution.

For purposes of this definition, "health care plan" shall not include indemnity health insurance policies including those using a contracted provider network;

(f) "Managed care plan" or "plan" means any health maintenance organization or prepaid limited health service organization: Provided, That this article only applies to prepaid limited health service organizations to the extent of coverage and services these organizations offer;

(g) "Provider" means any physician, hospital or other person or organization which is licensed or otherwise authorized in this state to provide health care services or supplies.

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