WEST VIRGINIA
Offices of the Insurance Commissioner
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Allan L. McVey
Insurance Commissioner

West Virginia Healthcare Practitioner Uniform Credentialing

History of Uniform Credentialing 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 and 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

Uniform Credentialing Application Forms

General Instructions

Before completing the Standardized Credentialing Form or the Re-Credentialing 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.

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

The Re-credentialing Form must be utilized by these Hospitals, Health Plans, and other Healthcare Entities at the time you apply for reappointment.

Initial Appointment and 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 initial application  and reappointment submitted to Hospitals, Health Plans, and/or other Healthcare Entities.(Do not submit forms to the Offices of the Insurance Commissioner).

Forms

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

 Uniform Recredentialing form in Microsoft Word

 Uniform Recredentialing Form in Adobe Acrobat