Providers
The provider data model contains information on persons and organization that can provide health care services. This model is able to capture the structure of a provider organization. The provider data model contains provider groups to capture information on grouping of providers for network or contracting purposes.
Individual Providers
An individual provider is a person who provides health care services, such as a general practitioner, dentist, nurse or surgeon.
| 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). |
Initials |
The abbreviation of the first names 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 |
Name format function |
The dynamic logic function that is used to format the name |
Gender |
The gender of the person |
Bank account number |
The preferred bank account number for the provider |
Email address 1 |
The email address |
Email address 2 |
The second email address |
Business phone number |
The phone number that is used for business purposes |
Private phone number |
The private phone number |
Mobile phone number |
The mobile phone number |
Fax number |
The fax number |
Preferred language |
Preferred language for correspondence with this provider |
Language |
Language for correspondence with this provider |
Start date |
The start date of the provider |
End date |
The end date of the provider |
A provider’s start and end date indicate the validity period of that provider. These are checked against a claim line’s service date. The application will deny lines where the provider is not valid on the service date.
Constraints:
-
A specified e-mail address must comply with standards for specifying e-mail addresses
-
The language of a provider needs to be an installed language
Organization Providers
An organization provider defines as a non-natural (legal) person, authority or judicial body, such as a hospital, a hospital department, a PCP group practice or a doctor’s office. An organization provider can consist of one or more sub organizations and can be part of a larger provider organization.
| Field | Description |
|---|---|
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). |
Name |
The name of the organization |
Is part of organization |
The organization provider of which this organization is a part |
Bank account number |
The bank account number to which payments for the provider are to be made |
Email address 1 |
The email address |
Email address 2 |
The second email address |
Business phone number |
The phone number that is used for business purposes |
Private phone number |
The private phone number |
Mobile phone number |
The mobile phone number |
Fax number |
The fax number |
Preferred language |
Preferred language for correspondence with this provider |
Language |
Language for correspondence with this provider |
Start date |
The start date of the provider |
End date |
The end date of the provider |
A provider’s start and end date indicate the validity period of that provider. These are checked against a claim line’s service date. The application will deny lines where the provider is not valid on the service date.
Constraints:
-
A specified e-mail address must comply with standards for specifying e-mail addresses
-
The language of a provider needs to be an installed language
Provider Specialty
A specialty describes the specific health care competencies that a provider can have. A provider can have one or more time valid specialties. Examples of specialties are anesthesiology, dermatology and psychiatric hospital.
| Field | Description |
|---|---|
Provider |
The provider that has the specialty |
Specialty |
The specialty that the provider has |
Start date |
The first date that the provider is listed as having this specialty |
End date |
The last date that the provider is listed as having this specialty |
Constraints:
-
It is not allowed to have an overlap in time validity for provider specialties 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 can be 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.
| Field | Description |
|---|---|
Organization provider |
The organization provider on the address |
Street |
The street of the address |
House number |
The house number of the address |
Number addition |
The house number addition, such as a floor or apt. number |
City |
The city where the address is situated |
Country region |
The region of the country in which the address is situated (can be used for e.g. States and Departments) |
Country |
The country in which the address is situated |
Postal code |
The postal code of the address |
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 has become effective |
End date |
The date the address has stopped service |
Constraints:
-
The country and the country region of an address should match
-
If the upper indicators (specified on country level) for street, city, number addition, and the additional parts are true, the values should be entered in uppercase
-
The address parts should comply with the dynamic logic for address parts that may be specified at country level
A rendering address represents that an individual provider renders services on the address. This may be significant for processing claims, determining whom to pay or for accreditation and validation purposes.
| Field | Description |
|---|---|
Individual provider |
The provider that renders services on the address |
Service address |
The address that the provider renders services on |
Start date |
The date the address has become effective |
End date |
The date the address has stopped service |
Constraints:
-
It is not allowed to have an 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.
| Field | Description |
|---|---|
Individual provider |
The provider that has the title |
Title |
The title that the provider has |
Provider Identifiers
An individual provider or an organization provider can have multiple identifiers for example the Social Security Number, National License number etc.
A provider Identifier has the following fields:
| Field | Description |
|---|---|
Provider |
The person or organization that has the identifier. |
Identifier type |
The unique key that is used to identify the identifier type. |
Identifier |
The identifier with ID (can contain digits and characters). |
Ind enabled? |
Is the provider identifier valid? |
Identifiers Type
The identifier type defines the list of possible identifier types that a provider can have.
An identifier type has the following fields:
| Field | Description |
|---|---|
Code |
The type of identifier. |
Display Name |
The display name of the identifier. |
Access restriction |
The access restriction restricting access to the identifiers. |
Concealment expression |
This field specifies a regular expression, that controls the concealment of restricted identifiers. |
- Constraints
-
A concealment expression can only be specified if access restriction is specified.
Provider Groups and Affiliations
A Provider group is a list of providers; providers can connect to a provider group through provider group affiliations. In the US, the word commonly used for a provider group is 'network'.
Provider groups can be connected to a product or to individual benefit specifications of a product. The providers in provider groups connected to a product are considered 'In network' for that product. All other providers are considered to be 'Out of network'.
| 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.
| Field | Description |
|---|---|
Provider |
The individual provider or organization provider that is affiliated to the provider group |
Provider group |
The provider group to which the individual provider or organization provider is affiliated |
Start date |
The start date of the affiliation between provider and the provider group |
End date |
The end date of the affiliation between provider and the provider group |
Financial Holds
Financial holds prevent financial transactions that reference providers to which the hold applies from being included in financial messages (and therefore paid).
A provider can have no, one or multiple financial holds associated with it. A financial hold has the following fields:
| Field | Description |
|---|---|
Hold Type |
The hold type that is applied to the provider (hold types are user defined and can be picked from a list of values) |
Provider |
The provider to which the hold applies |
Status |
Active, Released or Expired |
Held By |
The user that applied the financial hold to the provider |
Hold Datetime |
The date and time the financial hold was recorded in the system |
Released By |
The user that (manually) released 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 expires automatically |
Hold comment |
A comment on why the financial hold was recorded on the provider |
Release comment |
A comment on why the financial hold was released |
Constraints:
-
Financial hold attributes can only be updated when the status of the hold is Active
-
Only expiration datetime, hold comment and release comment are updateable (as long as the status is Active)
-
Financial holds cannot be deleted
-
The expiration datetime of the financial hold should not lie in the past
Financial holds have no functional impact on calculating a claim’s benefits or the claims finalization process.
Financial holds on provider level apply to all financial transactions with at least one financial transaction detail process data with a payment receiver and/or payment beneficiary being a provider that is on hold.
Provider Configuration
The following section describes the setup that supports the provider data model. The only configuration specific for providers is the list of available specialties. Titles, prefixes, countries and country regions are described in the Relations Model.