How Provider Network Management Works

Provider Network Management in Health Cloud enables payers and provider groups to easily enroll providers, construct effective provider networks, and retain top healthcare talent. Provider Network Management streamlines provider enrollment and supports a range of contract types, network models, and provider relationships.

Note Provider Network Management is available in Enterprise and Unlimited editions of Health Cloud provisioned with the Health Cloud Provider Network Management Add-On license.

Here’s a high-level overview of how a provider becomes a part of a payer network:

• Payer network management team runs an analysis on the provider directory to identify the current and potential providers in the network.
• Payer recruiting team creates a marketing campaign or event to automate outreach and attract interested providers to increase participation.
• Provider receives campaign or attends events and registers. Providers also nominate other peer providers.
• Payer recruiting team receives a lead, initiates the recruiting process, and sends the application to the provider.
• Provider completes the online application using the provider portal.
• Payer credentialing team reviews application data for credentialing compliance and approves the application. The team then discusses the terms and needs along with key issues such as prior authorizations, reimbursements, claims processing, rates, and disputes. The team then creates and sends the contract.
• Provider receives and signs the physician's contract agreement (sometimes after negotiation).
• Payer contracting team sends the final signed contract along with provider directory information, claims process, payment schedule, and other onboarding materials to providers. This team internally sends the information to the network management team.
• Payer network management team activates the provider and initiates their onboarding. Guided workflows and automation replace manual processes to ensure effective records storage, retrieval, and retention, while also allowing for provider engagement in critical moments.
• As a member of the provider network, the provider partners with the health plan to deliver world class care to their members. They stay connected with the payer through ongoing outreach campaigns, portals, and personalized provider service. Payer network management team continues to measure network adequacy.