Providers Module Documentation

Overview

The Providers Module serves as the central hub for monitoring all medical providers within your network. This includes hospitals, pharmacies, laboratory & radiology centers, and doctors.

1. Concept: The Provider Plan

Before managing individual providers, it is essential to understand the Provider Plan.

Separation of Concerns: This structure creates a necessary separation between your internal policy management and the specific pricing lists negotiated with providers.

Pricing Flexibility: This allows for distinct pricing tiers for the same service. For example, a single CBC test may have three different price points: one for managers, one for employees, and another for pensioners.

Privacy: This approach ensures total privacy and security for every stakeholder in the ecosystem.

2. Onboarding Providers (Applications)

Providers, such as hospitals, join your network through Applications. When reviewing an application, you will encounter two primary tabs:

A. Details

This tab contains the administrative data for the provider:

Entity Information: Basic hospital or provider details.

Contact Info & Legal Paperwork: Essential documentation and communication channels.

Manager Notes: Internal notes regarding the provider relationship.

B. Pricing List

This tab lists the specific services the hospital has submitted for coverage under your insurance.

Why Providers Input Pricing: We empower providers to input their own pricing to ensure flexibility when prices update and to encourage them to take control of their day-to-day data operations.

Processing an Application

To process a provider request:

1.Review: Carefully revise the submitted pricing list.

2.Correction: If you identify incorrect items, approve only the correct ones and request that the hospital manager submit a new request for the corrections.

3.Approval: Select the Status, assign the Entity Class, add any necessary notes, and finalize the approval.

3. Provider Management & Monitoring

Once approved, the provider appears in the Provider Plan Listing. You can search for specific providers or filter the list by Entity Class.

Clicking on a specific provider item reveals three detailed sections:

A. Basic Info

Displays the entity details, manager information, and approved legal paperwork.

B. Contracts

This section lists all approved services and their agreed-upon prices.

Drill-Down: Clicking on a contract displays granular details, including specific pricing information and the identity of the approver.

C. Billing

The Billing section offers a unique, real-time aggregated view of the provider's financial activity. Key metrics include:

Total Visits: The total number of beneficiary visits to this provider.

Financials: Total amounts paid by beneficiaries and reimbursement amounts due.

Filtering: You can filter these records by month or a specific date range for precise auditing.