West Virginia Code of State Rules › Agency 64 - Health › Title 64 - LEGISLATIVE RULE WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES › Series 64-89B - Credentialing Verification Organization › Section 64-89B-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
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.