20-3451. Definitions

In this chapter, unless the context otherwise requires:

1. " Applicant" means a provider that submits a credentialing application to a health insurer to become a participating provider in the health insurer's network.

2. " Application" means an applicant's initial application to be credentialed as a participating provider.

3. " Credentialing" means to collect, verify and assess whether a provider meets relevant licensing, education and training requirements to become or remain a participating provider.

4. " Designee" means a third party to whom the health insurer has delegated credentialing activities or responsibilities.

5. " Health insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, medical service corporation or a hospital, medical, dental and optometric service corporation and includes the health insurer's designee. Health insurer does not include a pharmacy benefits manager as defined in section 20-3321.

6. " Loading" means to input a participating provider's information into a health insurer's billing system for the purpose of processing claims and submitting reimbursement for covered services.

7. " Participating provider" means a provider that has been credentialed by a health insurer or its designee to provide health care items or services to subscribers in at least one of the health insurer's provider networks.

8. " Provider" means a physician, hospital or other person that is licensed in this state or that is otherwise authorized to furnish health care services in this state.

9. " Recredentialing" means to confirm that a participating provider is in good standing by a health insurer or its designee and does not require submitting an application or going through a contracting and loading process.

10. " Subscriber" means a person who is eligible to receive health care benefits pursuant to a health insurance policy or coverage issued or provided by a health insurer.