Provider Network Management (Health) — Host-to-Host Integration

Purpose of Host-to-Host

Connect hospitals, clinics, and labs to verify member eligibility and benefits instantly.
Automate pre‑authorization and medical review; reduce turnaround times and leakage.
Exchange e‑claims, remittance advice, and denial codes for fast adjudication and payment.

Core Data Objects

Provider: ID, specialty, addresses, schedule, bank details, accreditation
Contract & Tariff: DRG/CPT/HCPCS codes, package rates, room & board, exclusions, effective dates
Member & Benefits: policy/plan, coverage, limits, copay/coins, waiting periods, exclusions
Eligibility Result: covered/not, limits left, copay, referral/PA required
Pre‑Authorization: diagnosis (ICD‑10), procedures (CPT/DRG), requested cost, documents, approval
Encounter & Claim: services, meds, consumables, clinician notes, ICD‑10/CPT, amounts
Remittance: approved amount, denials (CARC/RARC), adjustments, taxes, net pay
Events: eligibilityChecked, preauthRequested, preauthApproved, claimSubmitted, remitIssued

Example API Endpoints

GET /providers/search
Find providers by specialty, location, or contract

GET /benefits/eligibility
Check member eligibility & remaining limits

POST /preauth/requests
Submit pre‑authorization with ICD‑10/CPT & estimates

POST /preauth/{id}/decision
Approve/decline with notes & authorized amount

POST /encounters
Create patient encounter; attach services & docs

POST /eclaims/submit
Submit e‑claim (HL7 FHIR/EDI JSON)

GET /eclaims/{id}/status
Check adjudication status and denial codes

POST /remittance/advice
Send remit (EOB/EOP) & payment reference

POST /contracts/tariffs
Upload tariff packages & effective dates

POST /cards/verify
Verify e‑card QR/NFC for cashless access

POST /callbacks/status
Async updates back to provider HIS/LIS/RIS

Sample Eligibility Check

GET /benefits/eligibility?member=MBR-123456&provider=HOSP-88
-- RESPONSE --
{
  "member":"MBR-123456",
  "plan":"HEALTH-PLUS",
  "eligible": true,
  "limits": {"inpatientLeft": 250000000, "outpatientLeft": 3500000},
  "copay": {"outpatient": 50000},
  "requiresPreauth": true
}

Sample e‑Claim Submit

POST /eclaims/submit
{
  "encounterId":"ENC-77210",
  "diagnoses":[{"code":"S72.0","system":"ICD10"}],
  "procedures":[{"code":"27130","system":"CPT"}],
  "items":[
    {"code":"ROOM_BOARD_STD","qty":3,"unitPrice":850000},
    {"code":"MRI_BRAIN","qty":1,"unitPrice":3500000}
  ],
  "total": 6050000,
  "attachments":["dischargeSummary.pdf","images.zip"]
}

Reference Flows

Cashless Visit

Front desk scans e‑card → /cards/verify
System calls /benefits/eligibility
Coverage & copay shown; encounter opened

Pre‑Authorization

Provider submits /preauth/requests with ICD‑10/CPT
Medical review returns decision & authorized amount
Provider proceeds within approved scope

e‑Claim & Adjudication

Provider sends /eclaims/submit
System validates codes/tariffs; applies contract rules
Remittance advice issued with denials/adjustments

Payment & Reconciliation

Remit references payment batch in Billing/ERP
Provider matches EOB/EOP; disputes via portal/API
Data feeds to DW/BI for provider scorecards

Security & Controls

mTLS, OAuth2/OIDC; IP allow‑list; JWS request signing; short‑TTL tokens.
PHI/PII minimization; encryption at rest & in transit; access logs for documents.
Consent & purpose limitation; audit for eligibility and e‑claim actions.
Idempotency keys; replay protection; rate limiting for callbacks.

Monitoring & Audit

Eligibility success rate, pre‑auth approval rate, and turnaround time.
Denial rate by provider & code; resubmission ratio; package variance.
Provider scorecards: quality flags, documentation completeness.

What You Get

OpenAPI with FHIR/EDI mapping notes; Postman & mock server.
Code dictionaries (ICD‑10/CPT/DRG) references and tariff templates.
e‑Claim & remittance samples (JSON/CSV/PDF); denial code lists.
Provider portal widgets (eligibility, PA status, claims inbox).
Annual maintenance incl. change requests; on‑prem or cloud.