§ 20.3451

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

acy 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.