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.
Field | Description |
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The qualifier of the provider code, such as the National Provider Index in the United States. |
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The code of the provider (Unique in combination with the code definition) |
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The abbreviation of the first letters from the name of the person. |
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The first name of the person |
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The middle name of the person |
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The prefix to the last name of that person |
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The name of the person |
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The suffix of the person |
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The gender of the person |
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The bank account number for the provider |
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The primary email address with the IETF RFC2882 standards. |
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The secondary email address with the IETF RFC2882 standards. |
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The phone number of the provider used for business |
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The provider’s private phone number |
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The provider’s mobile phone number |
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The provider’s fax number |
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The provider’s preferred language for correspondence |
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The provider’s language for correspondence |
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The start date of the provider |
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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
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A specified email address must adhere to email address standards.
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The language of a provider needs to be an installed language.
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Organization Providers
An organization provider defines as a legal person, authority, or judicial body, such as:
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Hospital
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Hospital department
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PCP group practice
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Doctor’s office
An organization provider comprises one or more sub-organizations and is part of a larger provider organization.
Field | Description |
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The qualifier of the provider code, such as the National Provider Index in the United States. |
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The code of the provider (unique in combination with the code
definition). |
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The name of the organization |
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The organization of which the organization provider is a part |
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The bank account number for the payments to the provider |
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The primary email address with the IETF RFC2882 standard |
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The secondary email address with the IETF RFC2882 standard |
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The phone number of the organization used for business |
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The organization’s private phone number |
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The organization’s mobile phone number |
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The organization’s fax number |
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The organization’s preferred language for correspondence with the provider |
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The organization’s language for correspondence |
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The start date of the provider |
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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
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A specified email address must comply with the standards for email addresses.
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The language of a provider must be an installed language.
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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.
Field | Description |
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The provider that has the specialty |
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The specialty of the provider |
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The first date of the listed specialty with the provider |
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The last date of the listed specialty with the provider |
- Constraints
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A provider is not allowed to have an overlap in time validity with the same provider and specialty.
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The time validity of a provider specialty must be within the time validity of the provider.
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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.
Field | Description |
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The name of the organization provider |
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The street of the organization provider |
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The house number of the organization provider |
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Additional details, such as a floor or apartment number |
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The city of the organization provider |
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The region of the country where the organization provider is situated, for example, states and departments. |
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The country of the organization provider |
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The postal code of the organization provider |
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Used for additional (country-specific) address information |
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Used for additional (country-specific) address information |
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Used for additional (country-specific) address information |
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The date the address became effective |
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The date the address when the services stop |
- Constraints
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The country and the country region of an address must match.
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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.
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The address parts must comply with the dynamic logic for address parts specified at the country level.
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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.
Field | Description |
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The provider who renders services from the address. |
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The address of the provider to render services |
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The date when the services began at the address |
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The date when the services stopped at the address |
- Constraints
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Service is not allowed to overlap in time validity for rendering addresses with the same individual provider and service address.
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Provider Title
An individual provider can have one or more titles.
Field | Description |
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The provider that has the title |
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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:
Field | Description |
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The person or the organization with the identifier |
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A unique key to identify the identifier type |
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The identifier with ID. It can contain digits and characters. |
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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:
Field | Description |
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The type of identifier |
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Indicator to show whether the identifier is unique |
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The display name of the identifier |
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The access restriction that restricts access to the identifiers |
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A regular expression to control and conceal restricted identifiers |
- Constraints
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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.
Field | Description |
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The unique code of the provider group |
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The description of the provider group |
Provider group affiliations represent the participation of a provider in a provider group.
Field | Description |
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The individual provider or organization provider affiliated with the provider group |
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The provider group of the individual provider or organization provider |
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The start date of the affiliation between the provider and the provider group |
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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:
Field | Description |
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The hold type that applies to the provider. A user can define hold types and pick them from a list of values. |
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The provider to which the hold applies |
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Active, Released, or Expired |
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The user who applies the financial hold to the provider |
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The date and time when the financial hold was recorded in the application |
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The user who releases the financial hold from the provider |
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The date and time the financial hold was released |
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The date and time the financial hold automatically expires |
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Comment on why the financial hold was recorded on the provider |
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Comment on why the financial hold was released |
- Constraints
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Financial hold attributes are updatable only when the status of the hold is active.
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Only expiration
datetime
,hold comment
, andrelease comment
are updatable when the status is active. -
Financial holds cannot be deleted.
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The
expiration datetime
of the financial hold must not be in the past.
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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.