Providers

This chapter describes providers. It includes the following topics:

About Providers

Providers are healthcare professionals who are paid by, or file claims with, your health plan or health insurance company. Examples of providers are physicians, nurse practitioners, dentists, and pharmacists.

The Providers screen allows end users to manage information about providers. Specifically, it allows end users to add and track information about providers and contracts, locate providers, associate facilities with a provider, indicate a provider’s specialties, add profile information (such as provider skills, background, and business locations and hours), add some provider claims (such as, an out-of-service-area claim), view payment information, and print a Provider report.

Scenario for Adding and Managing a New Provider

This scenario features sample tasks performed by a contracting specialist, a provider relations representative, and a member service representative. Your company might follow a different workflow according to its business requirements.

In this scenario, a contracting specialist for a health plan is responsible for managing information about the healthcare providers with which her company does business. She just established a contract with a single provider.

She adds the new provider and then adds information about the provider’s area of specialization. Next, she adds information about the provider’s primary location (for example, a medical group or pharmacy), affiliations (such as hospitals or health networks), and whether or not hospital affiliations include admitting privileges. After that, she adds information about the provider’s skills, background, and clinic locations and hours. Then she adds information about contracts the provider holds with her company and adds the provider’s payment preferences.

A provider relations representative provides service for the provider. He uses the:

Encounters view and the Claims view to refer to reports regarding patient visits and claims
Payments view to refer to payments made to the provider
Service Requests view to add service requests such as referral inquiries
Alerts view to add important notes about this provider

A member service representative uses Siebel Healthcare to answer questions about contracted providers. Using the Provider Locator, she searches for providers by city, state, or ZIP Code. She views and prints Provider reports based on the product and speciality. Also, she can view some of the information the contracting specialist adds in the Providers screen and the Products screen. For example, the Products screen displays information about providers in the Primary Providers view and the Contracted Providers view.

In this scenario, end users are health plan contracting specialists, provider relations representatives, and member service representatives. They use Siebel Healthcare to:

Add a new providers and provider addresses
Associate a facility with a provider
Associate a specialty with a provider and add profile information
Add a provider contract
View provider payments
Add a provider claim
View and print provider reports

End-User Procedures for Providers

The following end-user procedures are described in this section:

Adding Providers

End users use the Providers screen to add or make changes to healthcare provider records. After they add provider records in the Providers screen, users can view them in the Providers and the Contacts screen. In the Contacts screen, a check mark appears in the Provider field of the record, indicating that the contact is a provider.

Note: End users can add healthcare provider records in the Contacts screen. However, they will not appear in the Providers screen unless they check the Providers check box on the More Info view tab.

To add a provider

Navigate to the Providers and then the Providers List view.
In the Providers list, add a record and complete the necessary fields.

Adding Addresses for the Provider Locator

Users must add provider addresses if they want to use the Provider Locator feature.

To add a provider address

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Addresses view tab.
In the Addresses list, add a record.
In the Add Address dialog box, perform the appropriate task:
- To choose an existing record, select a record and click OK.
- To add a new record, click New and complete the fields.
In the Addresses list, click Update Geo Code.

Note: The latitude and longitude values will not generate if any one value in the City, State, Zip Code, or Country fields is incorrect. For example, if the ZIP Code is incorrect, you will receive an error message. To correct this problem, navigate to the Application Administration, ZIP Code Administration view and make sure the Geo values for that city, state, and ZIP Code combination has been loaded. For more information, see Siebel Self Service Administration Guide.

Associating Facilities with Providers

A provider might be affiliated with one or more facilities. For example, a provider might work at both a clinic and a hospital. End users can use the Affiliations view to associate facilities, such as clinics, hospitals, or pharmacies, with providers.

To associate a facility with a provider

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Affiliations view tab.
In the Affiliations list, add a new record.
In the Facilities dialog box, perform the appropriate task:
- To choose an existing record, select a record and click OK.
- To add a new record, click New and complete the fields.

Associating Specialties with Providers

Many providers have an area of medical specialization. End users can use the Specialties view to indicate a provider’s area of medical specialization by associating specialities with the provider.

To associate a specialty with a provider

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Specialties view tab.
In the Specialties list, add a record and complete the necessary fields.

Note: To add a new Specialty, you must add a new value to the List of Values (LOV) by specifying the Type as FINS_AGDESG_HLTHSPEC_MLOV. For more information, see Siebel Applications Administration Guide.

Adding Profile Information

End users can use the Profile view to add profile information for providers. Profile information includes provider skills, background, business hours, and business locations.

To add profile information

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Profile view tab.
In the Skills and Background form, complete the necessary fields.
Scroll down to the Hours & Locations list.
In the Hours & Locations list, add a record and complete the necessary fields.

Adding Provider Contracts

A company might have one or more contracts with each provider with whom they do business. Each contract might have different terms, payment preferences, and payment methods. End users can use the Contracts view to add contracts with providers.

End users can set up different payment arrangements and methods for each provider contract.

To add a provider contract

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Contracts view tab.
In the Contracts list, add a record and complete the necessary fields.
Scroll down to the Payment Preferences form.
In the Payment Preferences form, from the drop-down list, select one of the following:
- Payment Preferences - Check. To pay using a check.
- Payment Preferences - EFT. To pay using an electronic funds transfer.
In the selected Payment Preferences form, complete the necessary fields.

Viewing Provider Payments and Adding Payments Manually

End users can use the Payments view to review information about payments their company makes to providers. Payment information can include payment amount, payment date, payment adjustments, and reason for payment.

To view a provider payment

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Payments view tab.

Adding Payments Manually

Provider payments are usually imported from an external billing system. You can add payments manually in the Providers list.

To add payments manually

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Payments view tab.
In the Payments list, add a record and complete the necessary fields.

Note: You can scroll down to the Payment Details form to see additional fields.

Adding Provider Claims

A contract with a provider might specify that the provider is paid for each member visit or service. If so, providers or members might contact your company to initiate claims for payment. End users can use the Claims view to add claims for providers.

To add a provider claim

Navigate to the Providers and then the Providers List view.
In the Providers list, drill down on the desired provider.
Click the Claims view tab.
In the Claims list, add a record.
In the Add Claims dialog box, perform the appropriate task:
- To choose an existing record, select a record and click OK.
- To add a new record, click New and complete the fields.
Note: You can scroll down to the Claims form and complete additional fields.

Viewing and Printing a Provider Report

Provider reports can be viewed and printed by product and speciality.

To view a report of My Providers

Navigate to the Providers screen.
From the Show drop-down list, select My Providers.

Note: Only the providers listed in the Providers list will appear in the report.
Click the Reports Icon on the application tool bar.
Select a report from the drop-down list:
- Provider by Speciality. Lists all the providers and their general information, sorted by their specialities (such as dermatology and pediatrics)
- Provider by Product. Lists all the providers with general information in the order of products (such as HMO Plus and PPO) with which they are contracted.
The Provider report appears in the Siebel Report Viewer.
To print the report, in the Siebel Report Viewer window, click the print button.
To return to the Providers list, close the Siebel Report Viewer.