Credentialing and Quality
Comprehensive credentialing workflows with primary source verification, re-credentialing cycles, and quality scorecards to ensure provider standards.
Provider Network Management Platform
Provider Network Management (Health)
Build and govern a high-quality health provider network. Onboarding and credentialing, contracts and tariffs, directories and geo-search, scorecards and audits, and remittance/EOB. Fully integrated with claims, billing, and portals for providers, customers, and employers.
Provider Network Impact
Network Suite
Quality, compliant, efficient
- Quality network with credentialed providers
- Lower leakage with contracted tariffs
- Faster payments with clean EOB
- Better coverage and member access
- Regulatory compliance and audit support
Optimized for Health Insurance
Comprehensive Provider Network Management
Our Provider Network Management system streamlines onboarding, credentialing, contracting, and performance monitoring. Ensure quality care, cost containment, and regulatory compliance.
Contracts and Cost Control
Manage fee schedules, DRG packages, and contracted rates. Pre-auth checks and tariff controls reduce leakage and improve cost containment.
Core Features
Complete Provider Network Capabilities
End-to-end features for provider management, from onboarding to performance monitoring. Ensure quality, compliance, and efficient operations.
Provider Master & Profiles
Hospitals/clinics/labs/doctors with specialties, services, contacts, and licenses.
Onboarding & Credentialing
Application intake, document collection, primary source verification, and re-credentialing cycles.
Contracts & Tariffs
Fee schedules/DRG/packages, effective dates, exclusions, and change management with approvals.
Provider Directories & Maps
Search by specialty/location, geo-distance, and availability. Directory export to portals.
Pre-Auth & Eligibility Hooks
Eligibility checks, pre-auth flow, and contracted rate validation.
Remittance & EOB
Remittance advice, EOB breakdowns, adjustments/appeals, and settlement summaries.
Scorecards & Audits
Quality, cost, turnaround, and denial rates with on-site audit checklists and CAPA.
Fraud/Waste/Abuse Signals
Anomalies by provider, upcoding/unbundling patterns, and outlier flags.
Communication & Notices
Circular letters, document packs, and policy/price updates with read receipts.
Dashboards & Reports
Network coverage, utilization, spend, denials, and performance trends.
Security & Compliance
PII/PHI protections, consent, access controls, and full audit logs.
Integrations
Claims/PAS/Billing, e-invoice/tax, payment gateway/banks, DWH/BI, and provider portal.
Integration and Deployment
Seamless Integration with Your Systems
The system integrates easily with claims, billing, and portal systems to ensure smooth provider workflows and data exchange.
Integration Options
- Claims/PAS/Billing system integration.
- Provider portal and communication tools.
- Maps/Geo services for directory search.
- Payment gateway and bank integration.
Deployment and Security
- Cloud or on-premise deployment options.
- PII/PHI protection with encryption.
- Backup and disaster recovery features.
- API-first architecture with SSO support.
Implementation Approach
Structured Rollout, Measurable Outcomes
A practical rollout approach to standardize provider network management. Validate the system with realistic provider data and workflows before full-scale deployment.
Before Go Live
- Process mapping and gap analysis for provider workflows.
- Configuration of credentialing, contracts, and tariff structures.
- Integration planning with claims, billing, and portal systems.
- System testing (SIT) and user acceptance testing (UAT).
- Training and readiness checklist across teams and branches.
After Go Live
- Active support and stabilization of the provider network system.
- Continuous improvements and management of change requests.
- Enhancements to scorecards and reporting capabilities.
- Ongoing security reviews and system performance tuning.
Rayterton can start without upfront payment. The focus is to validate fit through working workflows and real outputs before scaling rollout.