Key Takeaways

Well done! Understanding the relationship between providers, networks, and products is essential to the Kyruus Connect for Payers experience. Lets go over some key takeaways from each lesson in this course:

Defining Providers:

  • Provider: a person or organization that supplies a member with care or services. A provider can be a practitioner, organization, facility etc. 
  • Providers are either Person (P-type provider) or organizations (O-type provider) in health data
    • There may be different requirements based on the type of provider 
  • Providers are uniquely identified by the provider/location key combination in the Kyruus Connect for Payers Data

Defining Networks:

  • Network: the providers, persons and or organizations, that a health plan groups together and makes available to members
    • Network is uniquely identified by: local network code, provider network code (these values need to be the same)
    • Providers are placed into networks by assigning the provider a key/location key code combination for a given provider to the network code for a given network in the ProvNetworks file 

Defining Products:

  • Product: network or group of networks that represent the providers available for a given member, identified by a marketable name 
    • Products are defined in the Kyruus Connect for Payers data by the assignment of a product code
    • If the product you sell in marketplace is made up for a single network of providers, you could have a 1:1 relationship between the product code and the network code 
    • If the product you sell in marketplace is made up of more than one network, this is a many to one relationship and the product code will be mapped to multiple distinct network codes 

Connecting Providers to Networks and Networks to Products:

  • Providers are placed into networks by assigning the provider key/location key combination for a given provider at a location to the network code for a given network in the ProvNetwork file 
  • Networks allow health plan to to apply a greater differentiation in the providers that are available to members
  • Health plans determine what the network code will be for each network creaked 
  • Connecting networks to products: networks are assigned to products by aligning the provider’s network code to the product code 
  • Connecting networks to products: networks are assigned to products by aligning the provider’s network code to the product code

Connecting the Dots:

  • Health plans contract with providers, group those providers into networks and assign networks to products
  • A member must select a product code in order to perform searches for providers or cost estimates
    • through the PlanMenu & PlanMenuLink files (these power the Search by Plan menu experience) for public users
    • through the SAML for authenticated usersA provider record must be assigned to a valid network code
  • A network code must be assigned to a valid product code

Review and Tips:

  • Providers are contracted by health plans to provide service to members, they can be person (P) or organization (O), and are identified by the unique provider key/location key combination 
  • Networks group providers together and are the connector between a provider and product; networks are defined by a health plan
  • Products are represented in the Kyruus Connect for Payers data by the product code and need to have one or more valid networks assigned to it