20-3451. Definitions

356 words·~2 min read·/az/title-20/20-3451

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

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. "Complete credentialing application":

(a)Means an application that includes all the information, any required supporting documentation and a current authorization to access electronic documentation that a health insurer needs in order to process the credentialing request through a credentialing system that is developed by a nationally recognized, nonprofit alliance of health plans and trade associations, including a nonprofit organization that is incorporated as a mutual health corporation and that is working to streamline the business of health care.

(b)Includes a credentialing system that is operated by a dental services corporation.

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 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 and contracted by a health insurer 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. "Recredential" means to confirm that a participating provider is in good standing by a health insurer 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.