Master Provider File

The master provider id is usually the Federal ID or SSN. It can be a system assigned sequential number. The primary provider file contains both group and individual information (name, SSN, Tax ID, discount, discount days, provider type, and etc).

Address File

The address is the master provider id plus a 2-digit suffix used to identify unique office locations, billing addresses, and departments within a facility (e.g., Hospital Outpatient Surgical Facility).

Network Affiliations

Network id and provider or group id are combined to identify participation of an individual provider or group within a network affiliation (PPO, HMO). An individual provider or group may participate in an unlimited number of affiliations. Co-pay can be by % or by $.

Fee Schedules

Supported fee schedules include fee for service (UCR, HIAA, MDR, or RVS), capitation, percentage discount, and negotiated. This includes fee variations for participating and non-participating providers. Contract dates, discounts, discount days, and/or a table of conversion factors can be assigned to an employer, location, class, PPO, medical group, individual provider, or geographical region (state or zip code). A provider, provider group, or affiliation can be capitated on one benefit line, paid fee for service on a second, and have a unique discount on a third. Claims are paid according to the schedule that was in affect at the time the claim was incurred.

Capitation

Capitation payments are automatically generated by the membership system based on contract agreements for each age and sex category. Retroactive adjustments are automatically calculated for a period defined in the contract (up to 12 months). Capitation detail report showing amounts paid to Provider per Member.

Enrollment Limits

Limits can be set on provider/patient workload by means of a flag in the provider record to indicate whether the provider is accepting new patients.

Provider Updates

Provider updates can be received electronically or entered manually.

Notes

Extensive free form notes can be entered for a provider. These notes are integrated with the notes of the claims review/maintenance programs. These notes are automatically date stamped at the time of entry. They are viewed with the latest notes first. Notes can be flagged to always be on top.