BURLINGTON, Mass. — HealthEdge, a leading provider of healthcare administrative and care management solutions, has launched its new AI-driven Provider Data Management platform, designed to automate and streamline the maintenance of accurate healthcare provider information. The first successful deployment of the platform took place with PEHP Health & Benefits, a division of the Utah Retirement Systems that offers insurance plans to public employees across the state.
Maintaining accurate provider data is a critical but often cumbersome task for health plans, directly impacting claims processing, network management, and regulatory compliance. Outdated systems and fragmented data frequently lead to payment delays, manual claims adjudication, inaccurate provider directories, and potential regulatory penalties. HealthEdge’s new platform addresses these challenges by serving as a centralized source of truth, integrating data from various sources, and using automation to intelligently match, merge, and validate records—eliminating the need for manual reconciliation.
Anshul Pande, Executive Vice President and General Manager of HealthRules® Payer at HealthEdge, emphasized the scope of the problem the platform aims to solve. “One in five pended claims can be traced back to provider data issues. Many payers are still relying on spreadsheets and teams of employees to manage this complex process,” Pande said. “Our Provider Data Management platform is a cornerstone in our mission to transform healthcare through digital ecosystems and automation.”
The platform was developed in collaboration with multiple health plans, ensuring it aligns with real-world needs and integrates smoothly with existing operations. PEHP Health & Benefits became the first organization to implement the solution, deploying it across its complex provider network, which includes 65,000 practitioners, 16,000 organizations, and over 21,000 locations. The system went live in less than four hours, immediately addressing issues such as duplicate records and manual updates while improving compliance, operational efficiency, and data accuracy.
Lance Toms, Operations Management Director at PEHP, highlighted the rapid impact the platform has had on their operations. “Managing provider data has historically been difficult because of the varied formats and sources we receive. Since implementing HealthEdge’s solution, the timeliness and accuracy of our data have improved exponentially,” Toms said. “This has allowed us to reallocate the workload of two to five full-time employees, leading to significant cost savings while enhancing the member experience through fewer billing errors and faster access to care.”
The platform offers real-time data validation by cross-referencing trusted sources like the National Plan and Provider Enumeration System (NPPES), ensuring ongoing data accuracy. Automated updates ensure that any changes are promptly reflected across downstream systems, including HealthEdge’s HealthRules Payer, while discrepancies are flagged as workflow tickets, minimizing manual intervention. These features also help health plans comply with state and federal regulations, including the Consolidated Appropriations Act (CAA), which mandates provider data validation every 90 days.
HealthEdge Provider Data Management is the latest addition to the company’s suite of next-generation solutions aimed at improving healthcare operations. While designed to integrate seamlessly with other HealthEdge products, the platform can also be implemented independently, allowing health plans to leverage its automation capabilities to enhance decision-making, improve payment accuracy, and deliver better member services.
