Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 11 - (98-1) Heath Care Professional Credentialing Verification (As Amended) › Rule 19-3-11.03 - Definitions

Current through June 25, 2024
For purposes of this Regulation:
A. "Commissioner" means the Commissioner of Insurance.
B. "Credentialing verification" is the process of obtaining
				  and verifying information about a health care professional, and evaluating the
				  professional credentials of that health care professional, when that health
				  care professional applies to become a participating provider in a managed care
				  plan offered by a managed care entity.
C. "Health care professional" means a physician or other
				  health care practitioner licensed or certified by the state to perform
				  specified health services.
D. "Health care services" or "health services" means services
				  for the diagnosis, prevention, treatment, cure or relief of a health condition,
				  illness, injury or disease.
E. "Managed care contractor" means a person or corporation
				  that:
1. Establishes, operates or maintains a network of
				  participating providers;
2. Conducts or arranges for utilization review activities;
				  and
3. Contracts with an insurance company, a hospital or medical
				  service plan, an employer or employee organization, or any other entity
				  providing coverage for health care services to operate a managed care
				  plan.
F. "Managed care entity" means a licensed insurance company,
				  hospital or medical service plan, health maintenance organization (HMO), an
				  employer or employee organization, or a managed care contractor as defined
				  under G. above, that operates a managed care plan.
G. "Managed care plan" means a plan operated by a managed
				  care entity that provides for the financing and delivery of health care
				  services to persons enrolled in such plan through:
1. Arrangements with selected providers to furnish health
				  care services;
2. Explicit standards for the selection of participating
				  providers;
3. Organizational arrangements for ongoing quality assurance,
				  utilization review programs and dispute resolution; and
4. Financial incentives for persons enrolled in the plan to
				  use the participating providers, products and procedures provided for by the
				  plan.
"Participating provider" means a health care professional
				  licensed or certified by the state, that has entered into an agreement with a
				  managed care entity to provide health care services, products or supplies to a
				  patient enrolled in a managed care plan.
H. "Physician" means one who is educated and trained to
				  practice the art and science of medicine and who has received the degree of
				  doctor of medicine or osteopathy from an accredited and recognized school or
				  college of medicine or osteopathic medicine.
I. "Primary verification" means verification by the managed
				  care entity of a healthcare professional's credentials based upon evidence
				  obtained from the issuing source of the credential.
J. "Secondary verification" means verification by the managed
				  care entity of a health care professional's credentials based upon evidence
				  obtained by means other than direct contact with the issuing source of the
				  credential (e.g., copies of certificates provided by the applying health care
				  professional).
Miss Code Ann
				  §§
										83-5-1;
				  83-41-413 (Rev. 2011)