58-17-149. Definitions regarding retrospective payment of clean claims for covered services provided during credentialing period.
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Terms used in §§ 58-17-149 to 58-17-152 , inclusive, mean:
(1)"Application date," the date on which a health insurer or other entity responsible for the credentialing of health care professionals on behalf of the health insurer receives the health care professional's completed application for credentialing or change request;
(2)"Clean claim," as defined in § 58-12-19 ;
(3)"Health care professional," as defined in subdivision 58-17F-1(8);
(4)"Health insurer," as defined in subdivision 58-17-100(2);
(5)"Special Review," a supplemental review of a health care professional's completed application for credentialing or change request by a health insurer or other entity responsible for credentialing of health care professionals necessitated by credible evidence received by a health insurer or other entity responsible for credentialing of health care professionals as it relates to investigation of the following: action taken against the applicant's licensure status, action taken against the applicant's professional society status, verified complaints to facilities, or licensing agency regarding the applicant; the applicant's non-completion of training programs; a criminal proceeding brought against the applicant a malpractice claim brought against the applicant; loss of a Drug Enforcement Administration certificate or state-controlled substance certificate; loss of a Medicare or Medicaid certification status; or involuntary termination of credentialing by a different health insurer.