SolutionS
Provider Data Management Solutions
Clean data in. Fewer denials out.
Unified provider data that powers enrollment, claims, and member access securely and at scale.
Provider Data Management creates a single, reliable provider database by ingesting and reconciling records from sources such as CAQH, rosters, credentialing systems, and provider submissions. Automated matching and normalization remove duplicates and inconsistencies, while validations for NPI, DEA, demographics, and addresses reference authoritative datasets to keep information accurate and current. Proactive compliance controls, clear audit trails, and advanced reporting provide real time transparency into data quality and change history.
Interoperable workflows streamline enrollment and ongoing maintenance so verified provider details flow consistently to downstream uses including directories and revenue cycle operations. Role based reviews and approvals govern high risk updates, while scheduled validations and timely updates improve directory readiness and reduce claim denials tied to credential and taxonomy errors. Secure handling practices align with HIPAA requirements and support audit readiness across programs and regions.
Master Provider Profile
Consolidate identifiers, credentials, specialties, locations, and affiliations into a single, governed source of truth.
Multi‑Source Ingestion
Ingest CAQH, payer rosters, provider submissions, and third‑party data; normalize formats and resolve duplicates.
Data Quality & Validation
Automated checks for NPIs, licenses, DEA, taxonomy, sanctions, OIG/LEIE, and address standardization (CASS/NCOA).
Directory Compliance Controls
Enforce CMS/NSA timeliness and accuracy standards (e.g., 90‑day outreach, 48‑hour updates) with auditability.
Network & Affiliation Management
Track practice groups, facility privileges, plan participation, effective dates, and closed/open panels.
Change Management Workflows
Role‑based review/approval with evidence capture, SLAs, and exception handling for high‑risk updates.
API Sync to Downstream Systems
Publish verified data to enrollment, claims, prior auth, referral, and public directories with version control.
Monitoring & Analytics
Dashboards for freshness, completeness, match/merge rates, update cycle time, and claims denial attribution.
Benefits
- Reduce claim denials and rework by preventing credential, taxonomy, and address errors upstream.
- Improve member access and satisfaction with accurate, timely provider directories.
- Shorten update cycle times through automated validations and governed workflows.
- Strengthen compliance with CMS/NSA timeliness rules and accreditation audits.
- Unify fragmented data into a single source of truth synced across core systems.
- Lower administrative costs tied to returned mail, directory corrections, and claim edits.
- Increase network visibility with clear affiliations, participation, and effective dates.
- Scale confidently with high‑volume ingestion, automated QA, and API‑first distribution.