Healthcare · Payers and provider organizations

Provider data that matches everywhere it's published.

A provider's name, address, specialty and network status have to agree across the directory, credentialing, claims and the APIs regulators now require. When they don't, members call the wrong office and claims stall. We fix the data foundation underneath, starting with the provider and member masters.

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01 / Symptoms

What it looks like.

Directory entries that disagree with credentialing records.
The same provider under several IDs across networks and claims systems.
Member records that don't resolve across lines of business.
Manual re-verification every quarter.

02 / Where it breaks

Where it breaks, area by area.

Master and reference dataThe same provider under several IDs across networks, credentialing and claims; member records that don't resolve across lines of business.Data qualityDirectory entries that disagree with credentialing records; manual re-verification every quarter.Data governanceNo single owner for provider data, so each system keeps its own version.Data integrationPatient, provider and payer-to-payer API exchanges that must resolve to the right member and provider.Data warehousing and BIClaims and payment integrity reports affected by duplicate provider and member records.Data for AI and analyticsPrior authorization and claims automation that reads the request correctly, then matches it to the wrong member or provider.

03 / Why now

Why this year.

Under the No Surprises Act, plans verify provider directory information at least every 90 days and update changes within two business days.

Source: Premera provider notice

Jan 1, 2027

CMS's Interoperability and Prior Authorization rule (CMS-0057-F) requires impacted payers to implement the Provider Access, Payer-to-Payer and Prior Authorization APIs by January 1, 2027 (CMS).

Source: CMS fact sheet

Each API exchange depends on member and provider records that resolve correctly.

04 / Where to start

Data Quality DiagnosticSee the offer MDM RescueSee the offer AI Data Foundation AssessmentSee the offer

05 / Experience

Member and provider master data are among the domains our team has delivered, alongside customer, product and counterparty masters.

Questions

We have an MDM for providers already.

Then the question is whether it's on the critical path for directory, credentialing and claims changes. If it isn't, see MDM Rescue.