Provider Network Ops

Network ManagementAsync jobs required

Risk-adjusted provider scoring, contract leakage modeling, and roster credential verification.

ProviderNetworkContract modelingCredentialingBenchmarking

About

Provider network operations. Scoring risk-adjusts a provider's member panel and benchmarks observed-vs-expected quality and cost against specialty peers with narrative negotiation drivers. Contract review models a fee schedule against paid claims to detect payment leakage and reprice proposed scenarios. Credential check cross-references a roster against NPPES, exclusion, and licensing sources.

How it works

  1. 1/score: panel risk adjustment (HCC) → O/E benchmarking → negotiation drivers (+ optional narrative)
  2. 2/contract-review: extract/accept fee schedule → model vs paid claims → leakage + scenario repricing → negotiation pack
  3. 3/credential-check: roster → NPPES / SAM / state lookups → staleness / exclusion / lapse flags (synchronous)

Intended use

  • •Value-based contract negotiation prep
  • •Payment-leakage detection against contracted rates
  • •Roster credential monitoring and re-credentialing

Key outputs

  • ▸score → per-provider O/E ratio, drivers, narrative
  • ▸contract-review → leakage findings, repricing scenarios, negotiation pack
  • ▸credential-check → per-provider credential flags (active / deactivated, exclusions, license)

Endpoints

Try each endpoint with your signed-in session — usage counts toward your monthly budget.

Use synthetic data only. Do not submit real patient records or PHI when testing endpoints.

Limitations & caveats

  • –Scoring needs claims-derived diagnoses (a panel is rejected if < 50% of members have diagnosis data)
  • –NPI / exclusion registries are synthetic stand-ins for external sources
  • –Scoring / contract narratives are LLM-driven (~30–90s); credential-check is instant