19 Miss. Code. R. 3-11.03
For purposes of this Regulation:
A. "Commissioner" means the Commissioner of Insurance.
B. "Credentialing verification" is the process of obtaining and verifying information about a health care professional, and evaluating the professional credentials of that health care professional, when that health care professional applies to become a participating provider in a managed care plan offered by a managed care entity.
C. "Health care professional" means a physician or other health care practitioner licensed or certified by the state to perform specified health services.
D. "Health care services" or "health services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
E. "Managed care contractor" means a person or corporation that:
1. Establishes, operates or maintains a network of participating providers;
2. Conducts or arranges for utilization review activities; and
3. Contracts with an insurance company, a hospital or medical service plan, an employer or employee organization, or any other entity providing coverage for health care services to operate a managed care plan.
F. "Managed care entity" means a licensed insurance company, hospital or medical service plan, health maintenance organization (HMO), an employer or employee organization, or a managed care contractor as defined under G. above, that operates a managed care plan.
G. "Managed care plan" means a plan operated by a managed care entity that provides for the financing and delivery of health care services to persons enrolled in such plan through:
1. Arrangements with selected providers to furnish health care services;
2. Explicit standards for the selection of participating providers;
3. Organizational arrangements for ongoing quality assurance, utilization review programs and dispute resolution; and
4. Financial incentives for persons enrolled in the plan to use the participating providers, products and procedures provided for by the plan.
"Participating provider" means a health care professional licensed or certified by the state, that has entered into an agreement with a managed care entity to provide health care services, products or supplies to a patient enrolled in a managed care plan.
H. "Physician" means one who is educated and trained to practice the art and science of medicine and who has received the degree of doctor of medicine or osteopathy from an accredited and recognized school or college of medicine or osteopathic medicine.
I. "Primary verification" means verification by the managed care entity of a healthcare professional's credentials based upon evidence obtained from the issuing source of the credential.
J. "Secondary verification" means verification by the managed care entity of a health care professional's credentials based upon evidence obtained by means other than direct contact with the issuing source of the credential (e.g., copies of certificates provided by the applying health care professional).
19 Miss. Code. R. 3-11.03