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Credential Definitions

  • “Applicant” means the Practitioner or Organizational Provider seeking to become credentialed or recredentialed to participate in CCHP's Network.
  • “Credentialing” is the process of assessing and validating the applicable criteria and qualifications of a Practitioner or Organizational Provider for participation in the CCHP Health Plan.
  • “Credentialing Authority” means the National Committee for Quality Assurance (“NCQA”), the Centers for Medicare and Medicaid Services (“CMS”), as applicable, and any other federal or state authority.
  • “Credentialing Committee” is a subcommittee of the Quality Oversight Committee that uses a peer review process to evaluate and make recommendations regarding credentialing decisions.
  • “Committee Members” means members of the Credentialing Committee appointed by the QOC and which includes Network participating health care professionals, such as physicians, allied health providers, and other medical and surgical specialties to provide advice and expertise for credentialing decisions.
  • “Covered Persons” means individuals who have insurance through CCHP.
  • “Credentialing Verification Organization” means an organization that conducts primarysource verification of practitioner credentials for other organizations. The NCQA CVO Certification program evaluates CVO management of many aspects of its credentials verification operations, as well as the process it uses for continuous improvement of services. 3
  • “Material Restriction” means any limitation or limiting condition imposed on a Practitioner’s ability to practice medicine.
  • “Medical Director” means the licensed physician appointed by CCHP to serve as the Chair of the Credentialing Committee and fulfill various duties related to CCHP administration.
  • “Mental Health Organizational Providers” means inpatient, residential, and ambulatory facilities, which provide mental health services to Covered Persons.
  • “Organizational Providers” includes an institution or organization that provides services, such as a hospital, residential treatment center, home health agency or rehabilitation facility.
  • “Practitioner” is a licensed or certified professional who provides medical care or behavioral healthcare services. “Primary Source Verification” means verification of credentialing information directly from the entity (e.g., state licensing board) that conferred or issued the original credential.
  • "Quality Oversight Committee" refers to the committee delegated the authority by the CCHP Board of Directors to implement, oversee and make final decisions regarding CCHP credentialing functions. The QOC may delegate to the Credentialing Committee the responsibility for selection, credentialing, recredentialing, and related administration of the credentialing process.
  • “Recredentialing” is the process of re-assessing and validating the applicable qualifications of a Practitioner or Organizational Provider to allow for participation in CCHP's Network. 

Medicaid

Children's Community Health Plan

PO Box 56099
Madison, WI 53705
1-800-482-8010

Together with CCHP

Children's Community Health Plan

PO Box 1997, MS 6280
Milwaukee, WI 53201
1-844-201-4672

 

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