Provider credentialing definition

Provider credentialing means the process undertaken by a health plan company to evaluate and approve a health care provider's education, training, residency, licenses, certifications, and history of significant quality or safety concerns in order to approve the health care provider to provide health care services to patients at a clinic or facility.
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Examples of Provider credentialing in a sentence

  • Board certification is verified during the Provider credentialing process.

  • Preauthorization approval shall be on a case by case basis, in the discretion of the Corporation, and contingent upon such program, and the Providers offering such program, complying with the Corporation’s Provider credentialing and medical policy requirements, which may change from time to time based on new evidence-based medical information available to the Corporation.

  • Provider credentialing must incorporate program integrity requirements.

  • Provider Appeal — A request from a Provider for reversal of a determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network.

  • Contractor shall remain responsible for Provider credentialing and re-credentialing.

  • Provider credentialing information is obtained from a variety of education resources.

  • Provider credentialing and Network oversight; iii Encounter Data; iv Claims processing; v Utilization Management; vi Complaint or Appeal; vii Quality assurance and marketing; viii Special investigation unit; and ix Those who are directly involved in the decision making and administration of the FWA detection program within the Dental Contractor’s organization.

  • The Provider credentialing policies and procedures must not discriminate against Providers that serve high risk populations or specialize in conditions that require costly treatment.

  • Organizational Provider credentialing files are confidential and are scanned into a secure imaging system.

  • Facility site reviews are conducted at the time of initial Provider credentialing process, and every three years thereafter.

Related to Provider credentialing

  • Credentialing means the process of collecting, assessing, and validating qualifications and other relevant information pertaining to a health care provider to determine eligibility and to deliver Covered Services.

  • Medicaid Provider Agreement means an agreement entered into between a state agency or other entity administering the Medicaid program and a health care operation under which the health care operation agrees to provide services for Medicaid patients in accordance with the terms of the agreement and Medicaid Regulations.

  • Provider Agreements means all participation, provider and reimbursement agreements or arrangements now or hereafter in effect for the benefit of Tenant or any Manager in connection with the operation of any Facility relating to any right of payment or other claim arising out of or in connection with Tenant’s participation in any Third Party Payor Program.

  • Provider agreement means the signed, written, contractual agreement between the department and the provider of services or goods.

  • Medicare Provider Agreement means an agreement entered into between CMS (or other such entity administering the Medicare program on behalf of the CMS) and a health care provider or supplier, under which such health care provider or supplier agrees to provide services for Medicare patients in accordance with the terms of the agreement and Medicare Regulations.

  • Provider panel means those providers with which a carrier contracts to provide health care services

  • Credential means a valid credential, life diploma, permit, or document in special education or pupil personnel services issued by, or under the jurisdiction of, the State Board of Education if issued prior to 1970 or the California Commission on Teacher Credentialing, which entitles the holder thereof to perform services for which certification qualifications are required as defined in Title 5 of the California Code of Regulations section 3001(g).

  • Primary Care Provider (PCP) means a health care professional who is contracted with BCBSAZ as a PCP and generally specializes in or focuses on the following practice areas: internal medicine, family practice, general practice, pediatrics or any other classification of provider approved as a PCP by BCBSAZ. Your benefit plan does not require you to have a PCP or to have a PCP authorize specialist referrals.

  • Provider Manual means a working document, including but not limited to BCBSM published bulletins and provider notices, that provide specific guidelines and direction by which providers may meet their contractual responsibility as described in this Agreement. Provider Manuals are published on web-DENIS.

  • Provider network means an affiliated group of varied health care providers that is established to provide a continuum of health care services to individuals;

  • Provider agency means a funded organization under contract with the Children’s Board to deliver and provide social services and supports to children and families of Hillsborough County, FL.

  • Provider Service means a Provider’s hosted online services (if any) as described in the Solution Exhibit which is provided by Provider to Customers located in the Territory through remote access via the Internet as part of the BPO Service. A Provider Platform Application shall be considered a Provider Service.

  • Provider contract means any contract between a provider and a carrier (or a carrier's network,

  • Provider of health care means a physician or physician assistant licensed pursuant to chapter 630, 630A or 633 of NRS, perfusionist, dentist, licensed nurse, dispensing optician, optometrist, practitioner of respiratory care, registered physical therapist, podiatric physician, licensed psychologist, licensed audiologist, licensed speech-language pathologist, licensed hearing aid specialist, licensed marriage and family therapist, licensed clinical professional counselor, chiropractor, licensed dietitian or doctor of Oriental medicine in any form.

  • Provider Personnel means all persons employed or engaged by the Provider together with the Provider’s servants, agents, consultants and Sub-Contractors (and all persons employed by any Sub-Contractor together with the Sub-Contractor’s servants, consultants, agents, Provider’s and Sub-Contractors) used in the performance of its obligations under this Agreement;

  • Provider Organization means a group practice, facility, or organization that is:

  • Training provider means an organization meeting the eligibility conditions as mentioned in Data Sheet and selected in accordance with the criteria set forth for the purpose.

  • Provider Group means a medical group, independent

  • Provider fee means the consideration paid for a service contract.

  • Local Service Provider (LSP means the LEC that provides retail local Exchange Service to an End User. The LSP may or may not provide any physical network components to support the provision of that End User’s service.

  • Extended foster care services means residential and other

  • Providers means individuals or organizations --------- licensed to practice dentistry (including specialists) as well as other dental professionals who provide ancillary reimbursable dental services.

  • Credentials means the unique log-in identifier entered via the Cloud Portal by which a person could access the Cloud Program.

  • Provider is any individual or company that provides professional or technical services.

  • Provider Enrollment means an agreement between the Department and a Medicaid provider to provide room and board and deliver care and services to a Medicaid eligible individual in an adult foster home for compensation.

  • Service Provider Personnel means and refers to Service Provider employees or subcontractors hired and maintained to perform Services hereunder.