Provider Master & Profiles
Hospitals/clinics/labs/doctors with specialties, services, contacts, and licenses.
Build and govern a high‑quality health provider network: onboarding & credentialing, contracts & tariffs, directories & geo‑search, scorecards & audits, and remittance/EOB — fully integrated with claims, billing, and portals for providers, customers, and employers.
Hospitals/clinics/labs/doctors with specialties, services, contacts, and licenses.
Application intake, document collection, primary source verification, and re‑credentialing cycles.
Fee schedules/DRG/packages, effective dates, exclusions, and change management with approvals.
Search by specialty/location, geo‑distance, and availability; directory export to portals.
Eligibility checks, pre‑auth flow, and contracted rate validation.
Remittance advice, EOB breakdowns, adjustments/appeals, and settlement summaries.
Quality, cost, turnaround, and denial rates with on‑site audit checklists & CAPA.
Anomalies by provider, upcoding/unbundling patterns, and outlier flags.
Circular letters, document packs, and policy/price updates with read receipts.
Network coverage, utilization, spend, denials, and performance trends.
PII/PHI protections, consent, access controls, and full audit logs.
Claims/PAS/Billing, e‑invoice/tax, payment gateway/banks, DWH/BI, and provider portal.
Directory/geo tools ensure members find the right providers fast.
Contracted tariffs and pre‑auth checks reduce leakage and abuse.
Scorecards and audits drive performance improvements.
Clear onboarding and communications improve provider relations.
EOB and remittance alignment make reconciliations faster.
Credentialing and logs support audits and regulator reviews.