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West Virginia Healthcare Practitioner

Uniform Credentialing Application Forms

PLEASE NOTE THAT THE UNIFORM CREDENTIALING AND RECREDENTIALING FORMS HAVE BEEN AMENDED EFFECTIVE OCTOBER 28, 2004.

The amended forms are now available on this web site by clicking on the links below. It is the West Virginia Insurance Commissioner’s position that the amendments do not require health care entities to take immediate steps to obtain amended forms from health care practitioners who have already been credentialed with the entity’s network. A health care practitioner will only be required to use the amended credentialing form in the event that he or she is applying for the first time for inclusion into a network. The amended recredentialing form will also be required at a health care practitioner’s next recredentialing date if that date is after October 28, 2004.

History Of Uniform Credentialing And Recredentialing Forms:

In accordance with legislation enacted by the West Virginia Legislature in 2001, the Uniform Credentialing Advisory Committee was appointed by the Secretary of the Department of Health and Human Resources and the West Virginia Insurance Commissioner to assist in developing a uniform credentialing process and implementing the use of uniform credentialing forms.

During 2001 and 2002, the Uniform Credentialing Advisory Committee developed the standardized forms with the goal of reducing the need for healthcare practitioners to complete multiple forms containing the same or similar information during the application and re-application process required by various entities.

The uniform credentialing and recredentialing forms were originally implemented on July 1, 2003. As noted above, the forms were amended effective October 28, 2004. The forms and list of practitioners subject to the forms are now part of a procedural rule that is designated in the West Virginia Code of State Rules as 64 CSR 89A. The original legislative rule is designated 64 CSR 89. The legislative rule will no longer contain the forms and list of practitioners, but should be consulted for additional requirements relating to the use of the forms.

 LIST OF PRACTITIONERS WHO SHALL USE THE UNIFORM FORMS

General Instructions

Before completing an initial form, please contact the Hospital, Health Plan, and/or other Healthcare Entity(ies) to which you are applying for instructions on how to proceed. The Healthcare Entity may require additional information along with this standardized form. You will be contacted by the Hospital, Health Plan, and/or other Healthcare Entity(ies) when it is time to complete the reappointment process.

These instructions have been developed for the healthcare practitioner's convenience in learning how to complete the credentialing documents (the Standardized Credentialing Form and the Recredentialing Form) that must be utilized by Hospitals, Health Plans, and other Healthcare Entities in performing credentialing activities in West Virginia.

Please note: You may downloaded the documents into Microsoft Word or print them from the Insurance Commissioner's website and complete by typing or hand printing.
 

Initial Appointment

The Standardized Credentialing Form will be utilized by Hospitals, Health Plans, and other Healthcare Entities at the time the practitioner is originally credentialed.

Please complete each section thoroughly and truthfully. DO NOT LEAVE ANY FIELDS BLANK. If an item is not applicable, indicate N/A.
Modification to the wording and format of the form will invalidate the application.
Attach additional sheets where necessary. (Indicate clearly the practitioner name and applicable section on each attachment.)
Type or print legibly in black ink.
Sign and date the application. (Some entities may require signature to be in blue ink.)
After completion of the application, you may photocopy and then submit with a signed attestation to each entity to which you wish to apply.
A listing of required documentation needed to complete the application process is contained on the first page of the application form.
You are responsible for providing current information at all times and to update substantial changes throughout the credentialing period. Please remember that you must sign and date a new attestation page each time your form is submitted.
The completed forms can be used for each initial application submitted to Hospitals, Health Plans, and/or other Healthcare Entities.

Options for Completing Forms

Following are brief instructions for the three options available for completing forms. The document has been formatted as a protected form file in Microsoft Word and can be

1. Downloaded into Microsoft Word and completed by computer. (This is the preferred option.)

a. Click on the Uniform Credentialing Form in Microsoft Word link on the Insurance Commissioner's web site. Download applicable form into Microsoft Word and rename the file; save file in appropriate directory.
b. Since the document has been protected, the Tab key will move the cursor from one check box or text box to the next.
c. Most text boxes will expand to allow completion of applicable information. Text boxes for phone numbers are set for a fixed number of digits.
d. Save completed form, print, sign where applicable, and copy for files. Include all applicable documents when mailing.
NOTE: Remember to save your work often. Also, it is advisable to save the application with a different filename after each update. Before you save, be sure you are not overwriting a file that should remain unchanged.

2. Printed from the Internet, completed by typing or hand printing, and mailed.

a. To open the Adobe Acrobat Version (PDF File), you must have Adobe Acrobat Reader. You can download Adobe Acrobat Reader for free by clicking on the link below.
b. Click the link to open the Uniform Credentialing Form in Adobe Acrobat version; once the form has opened, print the form.
c. Complete either by typing or hand printing legibly in black ink, sign where applicable, and copy for your files. Include all applicable documents when mailing.

Repeated Use of Forms

If option 1 is used, the saved form(s) can be updated as information changes. This allows the convenience of ongoing use of the form(s) for various entities.

If option 2 is used, the copied form(s) can continue to be utilized as long as the information on the form(s) is current and accurate. As information changes, those sections of the document can be updated and replaced.

Obtaining the Standardized Credentialing Form

Please click on the applicable link below to get Adobe Acrobat Reader and/or access the appropriate Credentialing Form.

Get Adobe Acrobat Reader

 Uniform Credentialing Form in Microsoft Word

 Uniform Credentialing Form in Adobe Acrobat

 

Reappointment

You will be contacted by the Hospital, Health Plan and/or other Healthcare Entity(ies) when it is time for your reappointment. The Recredentialing Form will be utilized by these Hospitals, Health Plans, and other Healthcare Entities at the time you apply for reappointment.

Please complete each section thoroughly and truthfully. DO NOT LEAVE ANY FIELDS BLANK. If an item is not applicable, indicate N/A.
Modification to the wording and format of the form will invalidate the application.
Attach additional sheets where necessary. (Indicate clearly the practitioner name and applicable section on each attachment.)
Type or print legibly in black ink.
Sign and date the application. (Some entities may require signature to be in blue ink.)
After completion of the application, you may photocopy and then submit with a signed attestation to each entity to which you wish to apply.
A listing of required documentation needed to complete the application process is contained on the first page of the application form.
You are responsible for providing current information at all times and to update substantial changes throughout the credentialing period. Please remember that you must sign and date a new attestation page each time your form is submitted.
The completed forms can be used for each reappointment application submitted to Hospitals, Health Plans, and/or other Healthcare Entities.

Options for Completing Forms

Following are brief instructions for the three options available for completing forms. The document has been formatted as a protected form file in Microsoft Word and can be:

1. Downloaded into Microsoft Word and completed by computer. (This is the preferred option.)

a. Click on the Recredentialing Form in Microsoft Word link below. Download applicable form into Microsoft Word and rename the file; save file in appropriate directory.
b. Since the document has been protected, the Tab key will move the cursor from one check box or text box to the next.
c. Most text boxes will expand to allow completion of applicable information. Text boxes for phone numbers are set for a fixed number of digits.
d. Save completed form, print, sign where applicable, and copy for files. Include all applicable documents when mailing.
NOTE: Remember to save your work often. Also, it is advisable to save the application with a different filename after each update. Before you save, be sure you are not overwriting a file that should remain unchanged.

2. Completed on this website and printed for mailing. (This option does not allow the completed form to be saved.)

a. Click on the Recredentialing Form to Complete on Website link below.
b. Since the document has been protected, the Tab key will move the cursor from one check box or text box to the next.
c. Most text boxes will expand to allow completion of applicable information. Text boxes for phone numbers are set for a fixed number of digits.
d. Print completed form, sign where applicable, and copy for files. Include all applicable documents when mailing.

3. Printed from the Internet, completed by typing or hand printing, and mailed.

a. To open the Adobe Acrobat Version (PDF File), you must have Adobe Acrobat Reader. You can download Adobe Acrobat Reader for free by clicking on the link below.
b. Click the link to open the Recredentialing Form in Adobe Acrobat version; once the form has opened, print the form.
c. Complete either by typing or hand printing legibly in black ink, sign where applicable, and copy for your files. Include all applicable documents when mailing.

Repeated Use of Forms

If option 1 is used, the saved form(s) can be updated as information changes. This allows the convenience of ongoing use of the form(s) for various entities.

If option 2 is used, the copied form(s) can continue to be utilized as long as the information on the form(s) is current and accurate. As information changes, those sections of the document can be updated and replaced.

Obtaining the Recredentialing Form

Please click on the applicable link below to get Adobe Acrobat Reader and/or access the Recredentialing Form.

Get Adobe Acrobat Reader

 Uniform Recredentialing form in Microsoft Word

 Uniform Recredentialing Form in Adobe Acrobat

 
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