Process Group

Provider Management

Objective

Verify provider credentials and qualified services and establish network assignments

Input

• Provider license

• Physical proximity

• Qualifying critera

• Maximum number of beneficiaries to which a provider can attend (i.e., level of services available based on staff)

• Provider type (doctor, hospital, health center, pharmacist,etc.)

• Provider banking information (e-payment)

Output

• Time-based validation of provider’s qualifications

• List of provider qualified procedures and services

• Provider Identifier

• Provider type

• Network referral relationships

Task Set

• Physical assessment of provider

• Credentialing

• Network referrals definition

• Provider agreement

Measurable Outcomes

• List of qualified/verified providers

• Updated list of qualified/verified providers

• List of credentialed services assigned to each provider

• Updated list of qualified/verified providers

Sources

• Joint Learning Network, 2012