HealthEdge Launches AI-Driven Provider Data Management Solution to the Market

BURLINGTON, Mass.--(BUSINESS WIRE)--HealthEdge^®, a leading provider of next-generation core administrative processing systems, payment integrity, and care management solutions, unveiled its HealthEdge Provider Data Management platform that empowers health payers to automate the tedious, yet critical task of maintaining accurate and updated information on healthcare providers. The company also announced the first deployment of HealthEdge Provider Data Management with PEHP Health & Benefits, a division of the Utah Retirement Systems that provides medical, dental, life, and long-term disability insurance plans to public employees.

Accurate provider data is the foundation of efficient claims processing, network management, and regulatory compliance. But for many health plans, maintaining clean, up-to-date provider records is a constant struggle. The traditional approach to provider data includes managing and utilizing outdated systems with scattered and various types of data, leading to payment delays, manual claims adjudication, inaccurate directories, and regulatory penalties. HealthEdge Provider Data Management serves as the single source of truth for provider data, ensuring accuracy, consistency, and complete data lineage across all health plan operations. With advanced automation, it enables seamless integration of data from various rosters and sources, and intelligently matches and merges records, eliminating the need for manual reconciliation.

“We have found that 1 in 5 pended claims can be attributed to provider data issues – and it’s not surprising when you consider that most payers are still using spreadsheets and dedicating multiple employees to managing this cumbersome, and complex task,” said Anshul Pande, EVP & General Manager HealthRules® Payer at HealthEdge. “Provider data really is a cornerstone of ensuring accuracy, consistency, and improving compliance across all health plan operations. Our new HealthEdge Provider Data Management platform is the latest step forward in our core mission of driving healthcare transformation through a single digital ecosystem and advanced automation.”

The HealthEdge Provider Data Management solution was designed and developed in close collaboration with several health plans, ensuring that it addresses their biggest challenges while integrating quickly and seamlessly with existing workflows. One of those health plans, PEHP Health & Benefits, was the first to implement HealthEdge Provider Data Management, and with its rapid deployment, the platform was fully operational and delivering value in less than four hours.

PEHP oversees a complex provider landscape, managing 65,000 practitioners and 16,000 organizations across 21,000 locations, with over 100,000 practitioner-to-location roles. Its HealthEdge Provider Data Management deployment immediately addressed challenges like duplicates and manual updates, while laying the foundation for ongoing improvements in compliance, automation, and operational efficiency.

“Inaccurate provider data can lead to a cascade of effects downstream in business workflow processes. But it’s historically difficult to manage because we continuously have data coming in different formats, from different sources, and across provider panels,” said Lance Toms, Operations Management Director at PEHP Health & Benefits. “Since we’ve implemented HealthEdge Provider Data Management, the timeliness and accuracy of our provider data has improved exponentially. It has freed substantial time and resources, enabling us to reallocate the time of two to five full-time employees previously tasked with provider data exchange, contributing directly to bottom line cost savings, while improving member experience by reducing billing errors, speeding path to care, and more.”

Through real-time validation during data ingestion, HealthEdge Provider Data Management verifies accuracy and completeness of provider data through cross-checks with trusted sources like the National Plan and Provider Enumeration System (NPPES). With automated roster updates, the solution can promptly make changes available for downstream systems, including HealthEdge’s HealthRules Payer, and flag discrepancies as workflow tickets, reducing manual interventions. These automated and timely updates help to improve compliance with state and federal regulations including the Consolidated Appropriations Act (CAA), which requires validation of provider data every 90 days.

HealthEdge Provider Data Management is the latest addition to the company’s next-generation integrated solutions suite. It allows health plans to converge their data and harness automation to drive more informed decisions, improve payment accuracy, foster meaningful collaboration and enhance member service and care delivery. However, it can also be purchased and implemented separately.

For more information, visit https://healthedge.com/solutions/provider-data-management/.

About HealthEdge:

HealthEdge® is building a future without limits for health plans, where they can deliver better service and care, make more informed decisions and streamline operations. Through an integrated platform of solutions for core administration (HealthEdge HealthRules® Payer), payment accuracy (HealthEdge Source™), provider network management (HealthEdge Provider Data Management), care management (HealthEdge GuidingCare®) and member experience (HealthEdge Wellframe™), health plans can converge their data and harness automation to drive more informed decisions, improve touchless transaction processing and payment accuracy, foster meaningful collaboration and enhance service and care delivery. HealthEdge is trusted by 116+ health plans, covering more than 110 million lives across 48 states. See what it means to converge without limits at HealthEdge.com and follow us on LinkedIn.

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