Data Sheet: Stay Ahead of a Shifting Regulatory Landscape with Provider Data Management
As the healthcare regulatory landscape is perpetually evolving, payer operations including provider data management, are frequently impacted.
As the healthcare regulatory landscape perpetually evolves, health plans face significant challenges in maintaining compliance across payer operations. From prior authorization adjustments to the Consolidated Appropriations Act (No Surprises Act), regulatory shifts demand agility and precision. This document details how HealthEdge's Provider Data Management solution empowers health plans to stay ahead of these curves, ensuring regulatory compliance while satisfying rigorous provider directory requirements.
Key Drivers for Provider Data Management
HealthEdge’s solution is engineered to support health plans in three critical areas of operation:
- Interoperability: Facilitating accessible provider data through seamless upstream ingestion and downstream distribution.
- Consumer Price Transparency: Ensuring provider directories remain up-to-date and accurate for member access.
- Payment Integrity: Streamlining claims processing mechanisms to ensure accurate, timely payments.
Strategic Capabilities
To function as a single source of truth for provider data, the platform delivers specific operational advantages:
- Up-to-Date Accessibility: Compliance with interoperability legislation requires data accessibility across the entire ecosystem. The solution provides native Core Administrative Processing Systems (CAPS) integration, configurable data distribution, and self-service data extracts to bridge PBMs, care management platforms, and member portals.
- High-Quality Validation: With over 300 built-in quality checks and third-party validations (including NPPES), the platform ensures data integrity. This high-quality data serves as the foundation for adhering to consumer price transparency rules.
- Strengthened Payment Integrity: By improving data accuracy, the solution reduces claims fallouts and overpayments. It specifically supports the determination of Qualifying Payment Amounts (QPA) for out-of-network providers, directly addressing requirements of the No Surprises Act.
The HealthEdge Difference
HealthEdge differentiates its Provider Data Management solution through the following technical attributes:
- Modern Architecture: A scalable, cloud-based, and web-based interface designed for future-proof agility.
- SaaS Delivery: A turn-key SaaS application that receives continuous upgrades to match industry shifts.
- Integration Readiness: Out-of-the-box integration with HealthEdge’s claims administrative processing system, HealthRules® Payer, alongside uncomplicated integration for other upstream and downstream systems.
- Comprehensive Cleansing: Advanced data cleansing validations to ensure operational reliability.
