Clinical Provider Management - Technical Specification

Healthcare provider credentialing and management system

Purpose

The Clinical Provider Management module handles individual healthcare providers who deliver medical services to patients. Each clinical provider must have a valid NPI (National Provider Identifier), be associated with one or more vendors, maintain current credentials, and have defined specialties. This module is critical for claim validation, authorization management, and ensuring only qualified providers deliver services.

Key Concepts

Term	Definition
Clinical Provider	Individual healthcare professional (doctor, therapist, etc.)
NPI	National Provider Identifier - unique 10-digit identification number
CAQH	Credentialing database for healthcare providers
Specialty	Medical specialty or area of practice
Credential	Professional qualification (license, certification, degree)
Privilege	Authorization to perform specific procedures
Provider Type	Category of provider (MD, DO, PT, DC, etc.)
Rendering Provider	Provider who personally performs the service
Supervising Provider	Provider who oversees mid-level providers
DEA Number	Drug Enforcement Administration registration

User Roles

Role	Description	Permissions
Credentialing Manager	Manages provider credentials	Full CRUD
Provider Relations	Provider relationship management	Read, Update
Medical Director	Clinical oversight	Read, Approve
Claims Processor	Validates provider on claims	Read only
Contract Manager	Reviews provider rates	Read
System Administrator	System configuration	All permissions

Field Documentation - Clinical Provider Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique provider identifier	Auto-generated CUID	Primary Key
NPI	String	Yes	National Provider ID	10 digits, Luhn check, unique	-
First Name	String	Yes	Provider first name	Max 100 chars	-
Middle Name	String	No	Middle name/initial	Max 100 chars	-
Last Name	String	Yes	Provider last name	Max 100 chars	-
Suffix	String	No	Name suffix (Jr, III, MD)	Max 20 chars	-
Degree	String	Yes	Primary degree	Enum: MD, DO, DC, PT, DPT, OT, PA, NP, etc.	-
Additional Degrees	String	No	Other degrees/certifications	Comma-separated	-
Provider Type	String	Yes	Type of provider	Enum: Physician, Therapist, Chiropractor, Nurse Practitioner, etc.	-
Gender	String	No	Provider gender	Enum: Male, Female, Other	-
Date of Birth	DateTime	No	Provider DOB	Past date, encrypted	-
SSN	String	No	Social Security Number	9 digits, encrypted, unique	-
Primary Specialty	Specialty	Yes	Main area of practice	Valid specialty code	Specialty
Secondary Specialties	Specialty[]	No	Additional specialties	Valid specialty codes	Specialty (Many)
License Number	String	Yes	State medical license	Alphanumeric	-
License State	String	Yes	State of licensure	2-letter state code	-
License Expiry	DateTime	Yes	License expiration date	Must be future if active	-
Additional Licenses	Text	No	Other state licenses	JSON array	-
DEA Number	String	No	DEA registration	Valid DEA format	-
DEA Expiry	DateTime	No	DEA expiration	Required if DEA present	-
CAQH ID	String	No	CAQH ProView ID	Numeric	-
CAQH Status	String	No	CAQH verification status	Enum: Complete, Pending, Expired	-
CAQH Last Verified	DateTime	No	Last CAQH check	Date of last verification	-
Medicare Number	String	No	Medicare provider ID	Alphanumeric	-
Medicaid Number	String	No	Medicaid provider ID	Alphanumeric	-
Vendor	Vendor	Yes	Primary employer/vendor	Active vendor required	Vendor
Additional Vendors	Vendor[]	No	Other vendor affiliations	Active vendors	Vendor (Many)
Primary Location	VendorLocation	Yes	Main practice location	Valid location	VendorLocation
Practice Locations	VendorLocation[]	No	All practice sites	Valid locations	VendorLocation (Many)
Email	String	Yes	Professional email	Valid email format	-
Phone	String	Yes	Office phone	10 digits	-
Mobile Phone	String	No	Cell phone	10 digits	-
Fax	String	No	Fax number	10 digits	-
Start Date	DateTime	Yes	Provider start date	Cannot be future	-
End Date	DateTime	No	Provider termination	After start date	-
Provider Status	String	Yes	Current status	Enum: Active, Inactive, Suspended, Credentialing	-
Status Reason	String	No	Reason for status	Required if not Active	-
Board Certified	Boolean	Yes	Board certification status	Default false	-
Board Name	String	No	Certifying board	Required if certified	-
Board Expiry	DateTime	No	Board cert expiration	Required if certified	-
Malpractice Insurance	Boolean	Yes	Has malpractice coverage	Default false	-
Malpractice Carrier	String	No	Insurance carrier	Required if insured	-
Malpractice Policy Number	String	No	Policy number	Required if insured	-
Malpractice Expiry	DateTime	No	Policy expiration	Required if insured	-
Supervision Required	Boolean	Yes	Needs supervision	Based on provider type	-
Supervising Provider	ClinicalProvider	No	Supervising physician	Required if supervision needed	ClinicalProvider
Privileges	Text	No	Hospital privileges	JSON array	-
Languages Spoken	String	No	Languages	Comma-separated	-
Accepting Patients	Boolean	Yes	Accepting new patients	Default true	-
Panel Status	String	No	Insurance panel status	Enum: Open, Closed, Restricted	-
Created At	DateTime	Yes	Creation timestamp	Auto-generated	-
Updated At	DateTime	Yes	Update timestamp	Auto-updated	-
Created By	User	Yes	Creating user	Valid user ID	User
Updated By	User	Yes	Updating user	Valid user ID	User
Appointments	Appointment[]	No	Provider appointments	-	Appointment (1:Many)
Authorizations	Authorization[]	No	Authorized services	-	Authorization (1:Many)
Claims	Claim[]	No	Submitted claims	-	Claim (1:Many)
Documents	Document[]	No	Provider documents	-	Document (1:Many)

Field Documentation - Provider Specialty Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique specialty ID	Auto-generated	Primary Key
Specialty Code	String	Yes	Standard specialty code	From taxonomy	-
Specialty Name	String	Yes	Specialty description	Max 200 chars	-
Category	String	Yes	Specialty category	Enum: Medical, Surgical, Therapy, Diagnostic	-
Requires Board Cert	Boolean	Yes	Board certification required	Default false	-
Requires Supervision	Boolean	Yes	Supervision required	Default false	-
Appointment Duration	Integer	Yes	Default appointment length	Minutes (15-120)	-
Active	Boolean	Yes	Specialty available	Default true	-

Workflows

Provider Onboarding Workflow

1. Initial Registration

   • Collect provider information
   • Verify NPI with NPPES
   • Check license status
   • Verify DEA if applicable

2. Credential Verification

   • CAQH profile check
   • License verification
   • Board certification check
   • Malpractice insurance verification

3. Specialty Assignment

   • Set primary specialty
   • Add secondary specialties
   • Verify specialty credentials
   • Set privilege levels

4. Vendor Association

   • Link to primary vendor
   • Add additional vendors
   • Assign practice locations
   • Set location schedules

5. System Setup

   • Configure appointment types
   • Set up rate schedules
   • Enable portal access
   • Configure preferences

6. Final Approval

   • Medical director review
   • Credentialing committee approval
   • Activate provider status
   • Enable for services

Credential Maintenance Workflow

1. Expiration Monitoring

   • Track license expiry
   • Monitor DEA expiration
   • Check insurance renewal
   • Board certification tracking

2. Renewal Process

   • Send renewal reminders
   • Collect updated documents
   • Verify new credentials
   • Update system records

3. CAQH Re-attestation

   • Quarterly CAQH check
   • Update provider data
   • Document verification
   • Status update

Provider Status Management

1. Status Changes

   • Review triggering event
   • Document reason
   • Update status
   • Notify affected parties

2. Suspension Process

   • Identify issue
   • Immediate suspension if needed
   • Investigation process
   • Resolution and reinstatement

Business Rules

NPI Validation Rules

• Must be exactly 10 digits
• Must pass Luhn algorithm check
• Must be unique in system
• Must match NPPES registry
• Cannot be changed once set

Credentialing Rules

• License must be active and current
• License state must match practice location
• DEA required for prescribing providers
• Board certification required for specialists
• Malpractice insurance mandatory

Supervision Rules

• Mid-level providers need supervising physician
• Supervisor must be active physician
• Supervisor must be at same vendor
• Maximum supervision ratio enforced
• Documentation of supervision required

Specialty Rules

• Primary specialty required
• Specialty must match credentials
• Board certification may be required
• Affects rate calculations
• Determines authorization requirements

Integrations

System	Integration Type	Purpose
NPPES Registry	REST API	NPI verification
CAQH ProView	API	Credential verification
State License Boards	Various APIs	License verification
DEA Database	Web Service	DEA verification
Vendor Management	Direct Database	Vendor associations
Claims Processing	Direct Database	Provider validation
Authorization System	Direct Database	Service approvals

Common Issues

Issue	Description	Resolution
Invalid NPI	NPI fails validation	Verify with NPPES
Expired License	Medical license expired	Suspend until renewed
CAQH Incomplete	Missing CAQH data	Request provider update
No Supervising Provider	Mid-level without supervisor	Assign supervisor
Credential Mismatch	Specialty doesn't match credentials	Review and correct

Screenshots Needed

• Provider Registration Form
• NPI Verification Interface
• Credential Management Dashboard
• Specialty Assignment Screen
• CAQH Integration Status
• License Tracking Grid
• Provider Profile View
• Location Assignment Map
• Supervision Configuration
• Document Upload Portal

Performance Considerations

• NPI lookup caching strategy
• Real-time CAQH API calls
• License verification frequency
• Provider search optimization
• Appointment availability calculation

Security Considerations

• SSN encryption mandatory
• PHI access controls
• Credential document security
• Audit trail for all changes
• DEA number protection

Notes

• CAQH verification runs nightly
• License expiration alerts sent 60 days prior
• NPI verification cached for 30 days
• Integration with medical boards varies by state