Providers

A provider data model contains information about people and organizations that provide healthcare services. This model captures the structure of a provider organization. The provider data model contains provider groups that capture information about the grouping of providers for a network or contract.

Individual Providers

An individual provider is a person who provides healthcare services, such as a general practitioner, dentist, nurse, or surgeon.

Table 1. Individual Providers
Field	Description
Flex code definition code	The qualifier of the provider code, such as the National Provider Index in the United States.
Code	The code of the provider (Unique in combination with the code definition) If no code is specified when entering a new provider record, the application generates a code using the dynamic logic function with signature Provider Code Generation.
Initials	The abbreviation of the first letters from the name of the person.
First name	The first name of the person
Middle name	The middle name of the person
Prefix	The prefix to the last name of that person
Name	The name of the person
Suffix	The suffix of the person
Gender	The gender of the person
Bank account number	The bank account number for the provider
Email address 1	The primary email address with the IETF RFC2882 standards.
Email address 2	The secondary email address with the IETF RFC2882 standards.
Business phone number	The phone number of the provider used for business
Private phone number	The provider’s private phone number
Mobile phone number	The provider’s mobile phone number
Fax number	The provider’s fax number
Preferred language	The provider’s preferred language for correspondence
Language	The provider’s language for correspondence
Start date	The start date of the provider
End date	The end date of the provider

A provider’s start and end date show the validity period of the provider. These are checked against a claim line’s service date. The application denies lines where the provider is not valid on the service date.

Constraints:

A specified email address must adhere to email address standards.
The language of a provider needs to be an installed language.

Organization Providers

An organization provider defines as a legal person, authority, or judicial body, such as:

Hospital
Hospital department
PCP group practice
Doctor’s office

An organization provider comprises one or more sub-organizations and is part of a larger provider organization.

Table 2. Organization Providers
Field	Description
Flex code definition code	The qualifier of the provider code, such as the National Provider Index in the United States.
Code	The code of the provider (unique in combination with the code definition). If code is not specified while entering a new provider record, the application generates a code using the dynamic logic function with signature Provider Code Generation.
Name	The name of the organization
Is part of organization	The organization of which the organization provider is a part
Bank account number	The bank account number for the payments to the provider
Email address 1	The primary email address with the IETF RFC2882 standard
Email address 2	The secondary email address with the IETF RFC2882 standard
Business phone number	The phone number of the organization used for business
Private phone number	The organization’s private phone number
Mobile phone number	The organization’s mobile phone number
Fax number	The organization’s fax number
Preferred language	The organization’s preferred language for correspondence with the provider
Language	The organization’s language for correspondence
Start date	The start date of the provider
End date	The end date of the provider

A provider’s start and end date show the validity period of that provider. These are checked against a claim line’s service date. The application denies lines where the provider is not valid on the service date.

Constraints:

A specified email address must comply with the standards for email addresses.
The language of a provider must be an installed language.

Provider Specialty

A specialty describes the specific healthcare competencies of a provider. A provider can have one or more time-valid specialties like anesthesiology, dermatology, and a psychiatric hospital.

Table 3. Provider Specialty
Field	Description
Provider	The provider that has the specialty
Specialty	The specialty of the provider
Start date	The first date of the listed specialty with the provider
End date	The last date of the listed specialty with the provider

Constraints:

A provider is not allowed to have an overlap in time validity with the same provider and specialty.
The time validity of a provider specialty must be within the time validity of the provider.

Service Address and Rendering Address

A service address is assigned to an organization, for example, a specialist center for a hospital, but can also exist stand-alone, for example, a general practitioner’s office.

Table 4. Service Address and Rendering Address
Field	Description
Organization provider	The name of the organization provider
Street	The street of the organization provider
House number	The house number of the organization provider
Number addition	Additional details, such as a floor or apartment number
City	The city of the organization provider
Country region	The region of the country where the organization provider is situated, for example, states and departments.
Country	The country of the organization provider
Postal code	The postal code of the organization provider
Additional part 1	Used for additional (country-specific) address information
Additional part 2	Used for additional (country-specific) address information
Additional part 3	Used for additional (country-specific) address information
Start date	The date the address became effective
End date	The date the address when the services stop

Constraints:

The country and the country region of an address must match.
If the upper indicators (specified on a country level) for street, city, number addition, and the additional parts are true, the values must be in uppercase.
The address parts must comply with the dynamic logic for address parts specified at the country level.

A rendering address represents the address from where an individual provider renders a service. This is significant for processing claims, determining who to pay, or accreditation and validation.

Table 5. Constraints
Field	Description
Individual provider	The provider who renders services from the address.
Service address	The address of the provider to render services
Start date	The date when the services began at the address
End date	The date when the services stopped at the address

Constraints:

Service is not allowed to overlap in time validity for rendering addresses with the same individual provider and service address.

Provider Title

An individual provider can have one or more titles.

Table 6. Provider Title
Field	Description
Individual provider	The provider that has the title
Title	The title of the provider

Provider Identifiers

An individual or organization provider can have multiple identifiers, for example, the Social Security Number, National License Number, etc.

A provider identifier has the following fields:

Table 7. Provider Identifiers
Field	Description
Provider	The person or the organization with the identifier
Identifier type	A unique key to identify the identifier type
Identifier	The identifier with ID. It can contain digits and characters.
Ind enabled?	Indicator to show whether the provider identifier is valid

Provider identifiers are always unique per identifier type regardless of the unique indicator on the identifier type.

Identifiers Type

The identifier type defines the list of possible identifier types of a provider.

An identifier type has the following fields:

Table 8. Identifiers Type
Field	Description
Code	The type of identifier
Unique?	Indicator to show whether the identifier is unique
Display name	The display name of the identifier
Access restriction	The access restriction that restricts access to the identifiers
Concealment expression	A regular expression to control and conceal restricted identifiers

Constraints: A concealment expression must be specified if access restriction is specified.

Provider Groups and Affiliations

A provider group is a list of providers; providers connect to a provider group through provider group affiliations. In the US, the word commonly used for a provider group is a network.

Provider groups are connected to a product or individual benefit specifications of a product. The providers in a provider group connected to a product are considered in network for that product. All other providers are considered out of network.

Table 9. Provider Groups
Field	Description
Code	The unique code of the provider group
Description	The description of the provider group

Provider group affiliations represent the participation of a provider in a provider group.

Table 10. Provider Group Affiliations
Field	Description
Provider	The individual provider or organization provider affiliated with the provider group
Provider group	The provider group of the individual provider or organization provider
Start date	The start date of the affiliation between the provider and the provider group
End date	The end date of the affiliation between the provider and the provider group

Financial Holds

Financial holds prevent financial transactions that reference providers to hold from being included in financial messages and thereafter paid.

A provider can have no (zero), one, or multiple financial holds associated with it. A financial hold has the following fields:

Table 11. Financial Holds
Field	Description
Hold type	The hold type that applies to the provider. A user can define hold types and pick them from a list of values.
Provider	The provider to which the hold applies
Status	Active, Released, or Expired
Held by	The user who applies the financial hold to the provider
Hold datetime	The date and time when the financial hold was recorded in the application
Released by	The user who releases the financial hold from the provider
Release datetime	The date and time the financial hold was released
Expiration datetime	The date and time the financial hold automatically expires
Hold comment	Comment on why the financial hold was recorded on the provider
Release comment	Comment on why the financial hold was released

Constraints:

Financial hold attributes are updatable only when the status of the hold is active.
Only expiration datetime, hold comment, and release comment are updatable when the status is active.
Financial holds cannot be deleted.
The expiration datetime of the financial hold must not be in the past.

Financial holds have no functional impact on calculating a claim’s benefits or the claim’s finalization process.

Financial holds on the provider level apply to all financial transactions with at least one financial transaction detail process data with a payment receiver or a payment beneficiary being a provider on hold.

Provider Configuration

The following section describes the specialties that support the provider data model. The only entity specific to the provider configuration is the list of available specialties. See Relations for more information on titles, prefixes, countries, and country regions.

Specialties

A specialty is used by providers and claim lines. On a claim line, a specialty represents the context for rendering the service.

Table 12. Specialties
Field	Description
Code	The unique code of the specialty
Description	The description of the specialty