02 — Capability · BC-1870.30
Provider Network Management
Build and keep a network of contracted providers large enough to meet access standards, credential them, load their agreements and data correctly, and publish a directory members can trust. The provider's side of payer contracts is revenue cycle.
- Network Management
- Provider Contracting
- Network Development
In scope
- Network adequacy analysis and provider recruitment
- Provider agreements and fee schedule loading
- Health plan credentialing of network providers
- Provider data, directory accuracy and provider relations
Out of scope
- Negotiating payer contracts as a provider (see BC-1840.60)
- Hospital medical staff credentialing (see BC-1850.40)
- Contracts with suppliers of goods and services (see BC-640.20)
Realized by · 4
- Salesforce · Health Cloudpartial via BC-1870.30.30
- InterSystems HealthShare · Provider Directorystrong via BC-1870.30.40
- HealthEdge · HealthRules Language Configurationcore via BC-1870.30.20
- HealthEdge · Provider Atlas Edgepartial via BC-1870.30.40
Used in · 3
Build it · 1
Decomposes into · 5
- BC-1870.30.10Provider Network AdequacyMeasure members' access to each provider type against time, distance and wait standards, and recruit providers where the network falls short.
- BC-1870.30.20Provider Agreements & Fee SchedulesAgree terms with providers and load their fee schedules and payment rules so claims pay as agreed.
- BC-1870.30.30Network Provider CredentialingCredential and recredential network providers and facilities against plan and regulator standards before they join and on a fixed cycle.
- BC-1870.30.40Provider Data & DirectoryKeep provider demographics, locations, specialties and network status accurate, and publish a directory members can rely on.
- BC-1870.30.50Provider RelationsSupport contracted providers with education, issue resolution and performance reviews, and handle network exits fairly.