"Credentialing." The process of assessing and validating the
qualifications of a health care practitioner, including, but not
limited to, an evaluation of licensure status, education,
training, experience, competence and professional judgment.
"Enrollee." Any policyholder, subscriber, covered person,
covered dependent, spouse or other person who is entitled to
receive health care benefits from a health insurer.
"Federally qualified health center." A federally qualified
health center as defined in section 1905(l)(2)(B) of the Social
Security Act (49 Stat. 620, 42 U.S.C. ยง 1396d(l)(2)(B)), or a
federally qualified health center look-alike, that is a
participating provider with the Department of Human Services
under the act of June 13, 1967 (P.L.31, No.21), known as the
Human Services Code.
"Health care practitioner." As defined under section 103 of
the act of July 19, 1979 (P.L.130, No.48), known as the Health
Care Facilities Act. The term shall include a health care
practitioner at a federally qualified health center.
"Health insurer." As follows:
(1) An entity that contracts or offers to contract to
provide, deliver, arrange for, pay for or reimburse any of
the costs of health care services in exchange for a premium,
including, but not limited to, a Medicaid managed care
organization as defined under the act of June 13, 1967
(P.L.31, No.21), known as the Human Services Code, and an
entity licensed under any of the following:
(i) The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921.
(ii) The act of December 29, 1972 (P.L.1701,
No.364), known as the Health Maintenance Organization
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