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Provider Network Management Built for Health Plans
Accurate directories, continuous compliance, and governed provider data across every network you manage.
Provider Data Challenges Facing Health Plans
Directory Accuracy at Compliance Scale
CMS mandates directory updates within two business days of any provider change and verification every 90 days across your full network. Manual processes cannot meet that cadence without automation.
Ghost Network Liability
When members rely on a directory listing that is wrong, the health plan absorbs the cost-sharing difference under the No Surprises Act. Every inaccurate listing is now a direct claims liability, not just a compliance finding.
Delegated Data Without Control
Provider groups send roster data in different formats on different schedules. Without a governed ingestion process, delegated data is the single largest source of directory inaccuracy in most large health plans.
Star Ratings and Revenue at Risk
For Medicare and Medicaid plans, provider data inaccuracies directly affect CAHPS scores, network adequacy findings, and CMS Star Ratings. A drop in Stars translates directly to lost quality bonus payments.
Credentialing Gaps Between Cycles
A three-year credentialing cycle misses the sanction issued in month fourteen or the license that lapsed in month twenty-two. Without continuous monitoring, compliance events surface in a claim denial or an audit finding, not before.
How PRIME® Addresses Provider Data Challenges for Health Plans
Validate Every Provider Record Through Six Automated Layers
PRIME® verifies every provider record through six sequential layers, from primary source to human expert, producing timestamped evidence at each step. When CMS requests your accuracy analysis under the REAL Health Providers Act, the documentation is already assembled. No manual reconstruction required.
Monitor Demographics and Credentialing Data Between Every Cycle
Scheduled validation tells you what was accurate at the last cycle. Continuous monitoring tells you what changed the day after. PRIME® monitors practice locations, panel status, license standing, and sanctions in parallel so directory errors are caught before they become compliance findings.
Govern Delegated and Non-Delegated Roster Data From Every Source
PRIME® ingests roster files in any format from any provider group, normalizes the data, and runs every record through the same reconciliation workflow. Source attribution is applied at the record level so your team can trace any error back to its origin rather than correcting it only at the directory surface.
Credential Providers and Manage Payer Enrollment in One Workflow
PRIME® connects initial credentialing directly to payer enrollment, eliminating manual handoffs between teams. Re-credentialing workflows initiate automatically before each cycle, and continuous monitoring covers the period in between so no compliance event goes undetected.
Walk Into Every CMS Audit Fully Prepared
PRIME® produces audit-ready packages continuously: verification records, outreach logs, exception trails, and change history per provider. The question is not whether your directories will be audited. It is whether you already know what auditors will find.