The term “Provider” is ambiguous and covers a number of different entities and roles within the health care delivery system. A clear and concise glossary of terms is the foundation of clear communication between stakeholders. In this section we define the key terms applicable to the provider directory.

Affiliations

Affiliations describe the relationship/s between records in the database. The affiliations managed within the scope are:
·         Admitting privileges to a hospital

·         Group practice membership

·         IPA membership

·         Employed by (Federally qualified health center)

Sanator gathers and manages additional relationships that help describe the provider universe in more detail. These relationships are typically derived by rules within in the Sanator solution.

·         Legal ownership structure between organizations

·         Billing relationships

·         Geospatial relationships

Address

A USPS recognized address that will have a zip code and geospatial coordinates. Address types managed within the Sanator Directory are:

·         Mailing

·         Practice

·         Billing

Contracted Entity

A legal entity with a Tax ID that has a contractual arrangement with a health plan for one or more products. A contracted entity will have at least a contract address, a 1099 address and (typically) at least one mailing address. Contracted entities are not required to be listed in the Provider Directory but are necessary to tie contacted Organizations and Practitioners to the health plan products. Health plans may manage these legal entities separately from the traditional “Provider file.” Contracted entities should be connected to Practitioners or Organizations via a Tax ID or other unambiguous identifier.

Management Group

An organization that is responsible for managing the information for a group of providers. This may be an administrative person within the provider organization or a management group such as MedPoint.

Organization

A business, association or other organizational structure. Not all organizations will have National provider ID’s (NPI’s) but all organizations that have NPI’s will have NPPES Type 2 NPI’s. An organization will have a Tax ID (TIN or FEIN). The TIN is often used to tie an organization to the Contracted Entity.

Practioner

Individuals that provide healthcare services. Not all practitioners will have National Provider ID’s (NPI’s) but all practitioners that have NPI’s will have NPPES Type 1 NPI’s.

Practitioners covered include:

·         Physicians

·         Psychologists

·         Acupuncturists

·         Podiatrists

·         Chiropractors

·         Optometrists

·         Licensed Clinical Social Workers

·         Marriage and Family Therapists

·         Professional Clinical Counselors

·         Qualified Autism Service Providers

·         Nurse Midwives

·         Dentists

·         Nurse Practitioners

·         Physician Assistants

Product

The lowest level term used to describe a particular health plan product. If different tiers exist for a product, then each tier of product would be regarded as a unique product. Products are typically grouped by Line of Business such as Medicare Advantage or Individual and Family Plans.