Provider Network Management Module
End-to-end provider network lifecycle management including credentialing, contracting, directory maintenance, network adequacy analysis, and performance-based incentive programs.
Organization Relevance
How It Works
Providers enter the network through the credentialing workflow which verifies licenses, certifications, malpractice history, and sanctions. Contracts define reimbursement terms and participation requirements. The directory maintains real-time provider data for member access. Network adequacy analysis ensures compliance with time/distance and specialty requirements. Provider profiling scores performance for value-based arrangements.
Requirements
- CAQH ProView integration for credentialing
- NPPES NPI verification
- State license verification API access
- CMS PECOS enrollment verification
- Network adequacy modeling tools (GeoAccess or equivalent)
Target Audience
Provider Relations, Credentialing Teams, Network Management, Contract Negotiators, Quality Teams
Pages (9)
| Page | Purpose | Key Features |
|---|---|---|
| Provider Directory | Searchable provider directory with demographics, specialties, and network status | Provider search, Map view, Specialty filters, Network status |
| Provider Contracts | Manage provider contract terms, reimbursement rates, and effective dates | Contract management, Rate terms, Amendment tracking, Expiration alerts |
| Credentialing | Provider credentialing and re-credentialing workflow management | Application processing, Verification tracking, Committee review, Recredentialing alerts |
| Provider Incentives | Configure and track provider performance incentive programs | Incentive programs, Performance scoring, Payment calculation, Results reporting |
| Network Adequacy | Analyze and report network adequacy against regulatory requirements | Time/distance analysis, Specialty mapping, Gap identification, Compliance reporting |
| Provider Portal | Provider self-service portal for claims, authorizations, and account management | Claims inquiry, Auth submission, Payment history, Profile updates |
| Provider Profiling | Provider performance profiling using quality, cost, and utilization metrics | Performance scorecards, Peer comparison, Trend analysis, Outlier identification |
| Specialty Networks | Configure and manage specialty-specific provider networks | Specialty configuration, Center of excellence, Referral patterns, Access analysis |
| Tiered Networks | Manage tiered provider network structures with differential benefits | Tier assignment, Criteria configuration, Member impact, Performance tracking |
API Integrations
CAQH ProView APINPPES NPI Lookup APIFHIR PractitionerRole/OrganizationProvider directory API (CMS machine-readable)Provider portal API
Referenced Resources
NCQA Credentialing StandardsCMS Network Adequacy GuidelinesCAQH ProView StandardsCMS Provider Directory Requirements
Expected Results
Compliant, adequate provider networks with verified credentials, transparent directories, and performance-driven incentive structures supporting value-based care.