Skip to main content
logo Contact us

Brochure: Next Generation HealthEdge Provider Data Management

Published Date

Locating and validating information from siloed sources is like solving a giant crossword puzzle without clues. Separate systems and manual updates lead to pieces not fitting together...

Download PDF

HealthEdge Provider Data Management: A Next-Generation Solution

Managing provider data effectively is a critical challenge for health plans. Relying on legacy systems and manual processes often leads to siloed information, duplicate records, and costly errors that negatively impact member outcomes and payer performance. These outdated methods prevent payers from establishing a real-time data pipeline and an accurate provider data repository, which are essential for modern digital navigation experiences.

HealthEdge Provider Data Management is a next-generation SaaS solution engineered to solve these issues. It enables health plans to improve efficiency, enhance data accuracy, and ensure regulatory compliance, ultimately delighting both members and providers. Learn more about automating provider data accuracy with HealthEdge Provider Data Management.

The High Cost of Inaccurate Provider Data

Poor provider data carries significant financial and reputational consequences across the entire healthcare value chain. The industry spends billions annually to correct issues stemming from inaccurate information.

  • Directory Maintenance: The healthcare industry spends nearly $3 billion annually on provider directory maintenance, yet inaccuracies persist.

  • Error Correction: Health plans can spend $8 to $15 per claim to correct errors caused by inaccurate provider data.

  • Address Data: Inaccurate address data alone costs the U.S. healthcare system over $6 billion annually.

Overcoming Key Provider Data Management Challenges

Payers consistently face several core obstacles when managing provider data. These challenges lead to poor member and provider experiences, increased compliance risk, and operational inefficiencies.

  1. No Single Source of Truth: Data is often scattered across multiple, disconnected systems, making it impossible to maintain a consistent and reliable master record.

  2. Manual and Repetitive Processes: Homegrown solutions and manual updates on spreadsheets are error-prone and divert valuable employee time from high-value tasks.

  3. Inaccurate Claims and Payments: Flawed provider data is a primary cause of claim processing delays, payment errors, and provider abrasion.

  4. Regulatory Compliance Issues: Evolving regulations demand accurate and accessible provider data, and failure to comply can result in significant penalties.

Discover strategies for overcoming provider data challenges in HealthEdge’s “Overwhelming Data” blog.

“Since starting with HealthEdge Provider Data Management, we’ve been able to reduce between two and five full time employees just for data exchange alone and allocate their time differently. It’s an excellent bottom line cost savings that we can attribute to using the tool... We’re finding efficiency to allow our employees to level up and do things that bring more value than just data entry.”LANCE TOMS, OPERATIONS MANAGEMENT DIRECTOR, PEHP

See how Provider Data Management improves data value and workforce efficiency in real-world case studies.

The HealthEdge Provider Data Management Solution

HealthEdge provides a comprehensive, cloud-native platform designed to create a single source of truth for provider data. Its components work together to ingest, master, enrich, and distribute high-quality data.

Ingestion and Mastering

  • Rapidly ingests data from multiple internal and external sources.

  • Self-hydrates provider data from HealthRules Payer.

  • Utilizes a customer-defined provider master identifier.

  • Applies prebuilt match and merge rules for effective data mastering.

Enrichment and Workflow

  • Enriches data through a centralized framework with over 500 built-in quality checks.

  • Performs third-party validations, including NPPES, address standardization, and attestation.

  • Features a modern web application with an integrated workflow module for discrepancy resolution.

Distribution and Integration

  • Offers a self-service module to configure, schedule, and deliver data extracts.

  • Supports real-time and fuzzy API, along with event-based distribution.

  • Provides seamless, native integration with the HealthRules Payer core administrative processing system (CAPS).

Platform

  • Built on a cloud-native, SaaS architecture for high availability, unlimited scalability, and seamless upgrades.

  • Features a customer-extendable data model.

  • Uses a low/no-code framework to configure and automate source intake and distribution.

Explore the Provider Data Management FAQ and detailed data sheet for more information.

Ensuring Regulatory and Compliance Adherence

The healthcare regulatory landscape is in constant flux. HealthEdge Provider Data Management is designed to help health plans comply with current and future mandates.

  • Interoperability: Satisfies provider data requirements in legislation by ensuring data is up-to-date and accessible across the entire health plan ecosystem.

  • Price Transparency: Adheres to consumer price transparency rules by delivering high-quality, validated provider directory data.

  • Payment Integrity: Strengthens payment integrity and streamlines claims processing relative to the No Surprises Act by improving the accuracy of out-of-network provider data.

Seamless Integration Capabilities

HealthEdge Provider Data Management is designed to be Core Administrative Processing System (CAPS) agnostic, ensuring broad compatibility. It supports integration with HealthEdge’s proprietary solutions (HealthRules Payer, GuidingCare, Wellframe, HealthEdge Source) as well as external systems through configurable APIs.

Value of Integration:

  • Improve data quality

  • Maintain accurate provider directory listings

  • Streamline claims processing and mitigate denials

  • Increase payment accuracy

  • Reduce service call volume

  • Support regulatory compliance

Security-First Approach: Data Protection and Security

HealthEdge has built its ecosystem with a security-first approach. A 2024 survey revealed that 46% of payer executives list security as their highest priority. Our platform includes robust protections to ensure member and provider data is confidential and safe.

Security Feature

Description

Data Encryption

All sensitive data is encrypted at rest (AES-256) and in transit (TLS 1.2 or higher).

Infrastructure Protection

Customer data is hosted on Microsoft Azure in the U.S. using fault-tolerant, logically, and physically separated infrastructure.

Access Controls

Natively supports and requires Single Sign-On (SSO) and Role-Based Access Control (RBAC) to enforce the principle of least privilege.

Software Security

Employs a comprehensive third-party risk management program and rigorous security standards for all tools and components.

Personnel Security

All workforce members undergo background checks and receive role-based security training, including phishing simulations.

Certifications

The platform is HITRUST certified, demonstrating a commitment to the highest standards of security and privacy.

 

Streamlined Implementation and Migration

Transitioning from a legacy system is simplified with HealthEdge Provider Data Management.

  • Migration: The process begins with a one-time full load of provider data, followed by incremental changes and near real-time updates to ensure data remains current.

  • Implementation: The solution’s low/no-code framework and pre-configured workflows are designed for rapid implementation, allowing for a smooth and quick setup process.

To learn more about our full suite of solutions, browse all Provider Data Management insights and assets in the HealthEdge Resource Center.