Providers Introduction
In Oracle Health Insurance a provider is a practitioner or facility that provides healthcare services. The application uses provider records to accurately price and adjudicate claims linked to those providers.
There are two types of provider in the application, individual providers and organization providers. Individual providers are natural persons, such as dentists, surgeons and nurses. Organization providers are non-natural persons such as hospitals, clinics and practices.
The provider type is relevant when linking providers together, such as a practitioner working in a clinic. The provider type also determines which attributes are available on the provider record.
Provider Attributes
Nearly all attributes are optional, so whether or not an attribute is set is a decision based on the business need. For example, if none of the benefit and pricing configuration depends on a provider’s specialty code, then there is no need to attach specialties to the provider records.
Identifiers
Every provider has a unique code as its primary assigned identifier. This identifier is either system generated or assigned by an external source upon creating the provider record.
In addition, you can attach any number of alternative identifiers to the provider. The application uses these alternative identifiers to recognize the provider on incoming claims when it fails to recognize the relation by its primary identifier. This feature facilitates the import of claim files that rely on the provider’s legacy identifiers.
Specialties
Specialty codes or taxonomy codes indicate what type of care a provider renders. A provider can have any number of specialty codes. Each assigned code has a start and an end date. The available specialty codes are set up by the user. Specialty codes can be used for the configuration of pricing and benefits. For example, consider a benefit that only applies if the servicing provider is an oncologist.
Provider Groups
In Oracle Health Insurance, provider groups represent provider networks. A provider can be in any number of networks, and the participation of that provider has a start and end date. Provider groups are used for various configuration rules. For example, consider a product that applies a different benefit depending on whether the servicing provider is in the member’s plan network or not.
Assigned Members
The application is able to track the relationship between members and providers. A provider can have any number of assigned members. Every such assignment has a start date, and end date and a type. The types are set up by the user and they explain the nature of the relationship. Examples of assigned provider types are primary care physician or gynecologist. The relation between the member and the provider may be relevant for the adjudication of claims. For example, consider a benefit that only applies if the servicing provider is the patient’s primary care physician.
Service Addresses
An organization provider can have any number of service addresses, but only one can be active at any given time. An individual provider can render services on any number of service addresses. All service addresses and all connections between individual providers and service addresses have start and end dates.
Access Control
Providers are subject to the following access controls.
To see a provider’s alternative identifiers, you require access per identifier type. For example, to see a provider’s license number, you require access to the identifier type for provider license numbers. This access control only protects the identifier values; other attributes on the relation record are not protected by this access control.