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Problem Statement: Payers and Providers maintain different ids, making it challenging to match identities in real-time at scale. One of the ways this is tackled today is through exchange of member and provider rosters between Payer and Provider. However, this approach is impractical to implement at scale.
In general, data attributes required to match identities are the following
Provider: Ids (NPI/DEA/TIN), Name (First, Middle, Last), Addresses, Facility Names, Organization details, Date of Service, Specialty/Qualifications/Titles
Member: Ids (SSN, Subscriber Id, Medical Record Number, Patient Id), DOB, Name (First, Middle, Last), Addresses, Gender, Phone, Email (verified or secure email ids), Emergency contacts, Parental Info (e.g. Pediatrics use cases), Previous Names/Aliases, Race/Ethnicity, Date of Service
Anticipated Challenges
Resolving multiple matches in real-time
Dealing with scores/confidence levels for matches
Suggested next steps
Analyze FHIR Resources to provide local context to Id (e.g. Member Id/MRN/NPI)