U.S. Healthcare Payers’ Provider Network Management Applications Reviews and Ratings

What are U.S. Healthcare Payers’ Provider Network Management Applications?

Gartner defines provider network management (PNM) solutions as payer-industry-specific applications that assist payers in the management of their network of healthcare providers. Effective PNM is critical to success for both provider and member engagement, and experience for U.S. healthcare payers.

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Availity is focused on improving communication in the healthcare sector. The company develops an intricate network designed to aid in the transparent exchange of information among health plans, providers, and technology associates. As a leading health information network in the country, it assists in the execution of billions of clinical, administrative, and financial transactions every year. Availity's product suite is based on an intelligent platform that facilitates real-time collaboration, catering to the needs of a competitive, value-based care ecosystem.

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Optum, which now includes Change Healthcare, focuses on improving health system efficiency and aiding individuals in leading healthier lives. The key business problem these teams aim to resolve involves enhancing the functioning of the healthcare system, thus ensuing better health outcomes for all. The work does not only centre on individuals but extends to making the healthcare system more effective for everybody involved.

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Clarify Health is a healthcare data and analytics company focused on unlocking valuable insights to make complex care decisions easier for providers, payers, tech and services organizations, and life science companies. The Clarify Atlas Platform(R) forms the company's foundation for customers stack the building blocks necessary to grow topline, contain costs, guide care, and more. Powered by a dataset of over 300 million lives and more than 20 billion AI-powered predictions, Clarify’s offerings deliver actionable insights with speed and actionability.

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Clarify Health is a healthcare data and analytics company focused on unlocking valuable insights to make complex care decisions easier for providers, payers, tech and services organizations, and life science companies. The Clarify Atlas Platform(R) forms the company's foundation for customers stack the building blocks necessary to grow topline, contain costs, guide care, and more. Powered by a dataset of over 300 million lives and more than 20 billion AI-powered predictions, Clarify’s offerings deliver actionable insights with speed and actionability.

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Constellation4 is a technology firm that specializes in health sector solutions. The organization's main focus lies in efficiently solving common operational challenges faced by health insurance companies and healthcare providers. Using Salesforce Health Cloud, Constellation4 develops a comprehensive range of products tailor-made to aid in effective health management. The products range from a physician-to-physician referral platform aimed at increasing market share and patient status visibility to Provider Network Management and Provider Data Management solutions that streamline payer-provider workflows and ensure data accuracy. Additionally, Constellation4 also offers healthcare analytics that matures data science, predictive analytics, and AI processes. Use cases include but are not limited to claims reconciliation, profitability analysis, and campaign management.

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Constellation4 is a technology firm that specializes in health sector solutions. The organization's main focus lies in efficiently solving common operational challenges faced by health insurance companies and healthcare providers. Using Salesforce Health Cloud, Constellation4 develops a comprehensive range of products tailor-made to aid in effective health management. The products range from a physician-to-physician referral platform aimed at increasing market share and patient status visibility to Provider Network Management and Provider Data Management solutions that streamline payer-provider workflows and ensure data accuracy. Additionally, Constellation4 also offers healthcare analytics that matures data science, predictive analytics, and AI processes. Use cases include but are not limited to claims reconciliation, profitability analysis, and campaign management.

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Infosys is a company concentrated on providing digital services and consultation on a global scale. Originating from over 30 years of managing the infrastructures of significant global corporations, Infosys guides businesses through their digital transformation process. This is achieved by reinforcing the organization with an AI-controlled center that aids in outlining the implantation of modifications and by enhancing the industry with scalable agile digital. This approach aims to deliver unprecedented levels of organizational efficiency and consumer satisfaction. Furthermore, Infosys places a strong emphasis on continual learning to promote regular enhancement through the cultivation and transfer of digital proficiency, knowledge, and notions derived from its innovation ecosystem.

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MacroHealth is a company that concentrates on simplifying the purchasing and offering of healthcare services. The primary business problem the company resolves is optimizing healthcare pricing and payments by providing a Marketplace-as-a-Service platform. The platform is geared towards Payers, Providers, and Health Market Partners to streamline and interconnect their unique healthcare ecosystems. The Optimization solutions offered by MacroHealth focus on analytics and connectivity. They provide Payers with data improvement, analytical instruments, and market benchmarking to develop Provider network solutions that are customized for every unique member group. With their Connect solutions, a single EDI/API implementation is sufficient to establish a connection with chosen Providers, Provider Networks, and industry Partners. The overarching goal is the creation of Intelligent Health Markets to significantly improve healthcare cost, quality, and access.

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NantHealth, part of the NantWorks ecosystem, offers enterprise solutions assisting businesses in turning multifaceted data into usable insights. The primary focus lies on efficient data transference, interpretation, and visualization. This makes operational tasks simpler for companies across diverse sectors including healthcare, life sciences, logistics, and telecommunications, enabling them to automate and comprehend data-driven strategies while maintaining data security and scalability. The product range includes high-tech platforms aiding instant support for payer-provider coverage decision and data solutions facilitating multi-data analysis, reporting, and professional services provisions.

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Newgen is a company that specializes in providing a unified platform for digital transformation. This includes capabilities in process automation, content services and communication management. Its low code application platform is relied on globally, allowing businesses to develop and deploy complex, content-driven applications on the cloud. Newgen serves several uses cases across industries and is equipped to handle everything from onboarding to service requests and lending to underwriting, all in a fast and agile manner.

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Virtusa Corporation is a provider of digital engineering and technology services to globally operating companies. Through an 'Engineering First' approach, Virtusa aims to turn concepts into practical applications, enabling innovative solutions to critical business problems. The company blends logic, creativity, and curiosity to build strategies and create solutions, thereby addressing the prominent business challenges of global companies and helping them stay ahead in their industries. Inclusion and diversity are vital aspects within the company.

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Vee Technologies, established in 2000, is a consulting and professional services organization based in New York City. The firm maintains technology hubs in Bangalore with service centers located in the Philippines, Salem, Hyderabad, and Chennai. Providing advanced technology solutions, Vee Technologies aids in process optimization, cash flow increase, cost reduction, and compliance maximization. The company caters to enterprises across the globe, enhancing productivity and achieving quality and cost outcomes. Vee Technologies is experienced in various sectors including Strategy & Consulting, Healthcare, Product Engineering, IT Services, Logistics, Media, Finance & Accounting, e-Governance, and LPO. The company offers a range of services such as Revenue Cycle Management, Health Information Management, Healthcare Analytics, Robotic Process Automation, Risk Adjustment Optimization, Legal Process Outsourcing, and Animation.

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Simplify Healthcare is a company offering a broad range of products designed to assist payers in managing their healthcare benefits and provider interactions. The firm is powered by the Simplify Health Cloud™, a scalable, enterprise-grade, compliant, secure, and adaptable cloud platform. Simplify Healthcare has several primary offerings, including Benefits1™, Provider1™, Service1™, Claims1™, and Experience1™. These tools offer comprehensive solutions to complex issues, allowing for greater management of product, benefits, and provider data. In addition, the Simplify App Fabric™ empowers payers to build enterprise solutions at speed, using a low-code platform. Lastly, Simplify Healthcare AI™ provides ready-made artificial intelligence solutions designed to better sales, network performance, and service operations.

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Salesforce is a company that integrates artificial intelligence with customer relationship management and data to create solutions for customer-related concerns. Salesforce's primary business problem is to enhance the interaction between businesses and their customers by leveraging technology.

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Symplr is a company primarily focused on simplifying complex healthcare operations. The firm designs and develops the required tools to successfully deploy and streamline healthcare operations. Symplr aims to work collaboratively with healthcare providers to generate strategies that not only adapt to the changing medical landscape but also take advantage of staff and technology to maximize efficiency and productivity. With over 30 years of existence, Symplr has earned a reputation for enhancing healthcare operations with its variety of cloud-based solutions. These solutions include provider data management, workforce management, and compliance, quality, safety, and contract supplier and spend management tools. These technologies are specifically designed to alleviate administrative burdens, allowing health practitioners to focus more on providing top-tier patient care.

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Symplr is a company primarily focused on simplifying complex healthcare operations. The firm designs and develops the required tools to successfully deploy and streamline healthcare operations. Symplr aims to work collaboratively with healthcare providers to generate strategies that not only adapt to the changing medical landscape but also take advantage of staff and technology to maximize efficiency and productivity. With over 30 years of existence, Symplr has earned a reputation for enhancing healthcare operations with its variety of cloud-based solutions. These solutions include provider data management, workforce management, and compliance, quality, safety, and contract supplier and spend management tools. These technologies are specifically designed to alleviate administrative burdens, allowing health practitioners to focus more on providing top-tier patient care.

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Symplr is a company primarily focused on simplifying complex healthcare operations. The firm designs and develops the required tools to successfully deploy and streamline healthcare operations. Symplr aims to work collaboratively with healthcare providers to generate strategies that not only adapt to the changing medical landscape but also take advantage of staff and technology to maximize efficiency and productivity. With over 30 years of existence, Symplr has earned a reputation for enhancing healthcare operations with its variety of cloud-based solutions. These solutions include provider data management, workforce management, and compliance, quality, safety, and contract supplier and spend management tools. These technologies are specifically designed to alleviate administrative burdens, allowing health practitioners to focus more on providing top-tier patient care.

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Virsys12 is a healthcare technology company bringing automation and AI to the provider lifecycle management issues with healthcare payers, health systems, ICNs, MCOs, Benefit managers, TPAs and other "at risk" healthcare organizations that fact increasing cost pressures and revenue leakage. From provider onboarding, credentialing, contracting with fee schedules, and claims activation to ongoing provider data challenges, V12 Enterprise handles the most complex provider network challenges in fee for service and value based care networks.

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Features of U.S. Healthcare Payers’ Provider Network Management Applications

Updated June 2025

Mandatory Features:

  • Dashboards and reports — These are used to understand completion rates of enrollments and the necessary accreditations and licenses. This information is critical as the provider cannot be offered to members or groups without this information being completed.

  • Data security and privacy — Enables adherence to industry or regional regulatory and compliance standards. This includes standards such as Health Information Technology for Economic and Clinical Health (HITECH), National Institute of Standards and Technology (NIST) or Service Organization Control Type 2 (SOC2) compliance.

  • Network design and tiering — Tools to identify and select providers to include in a network and help manage different levels of providers based on specific factors like cost and quality.

  • Provider/partner network and relationship management — These applications integrate all of the data sharing and workflows necessary to support the full life cycle of provider relationships. This includes network design composition, initial enrollment, credentialling, fee schedules for claims payment, performance monitoring reporting, provider servicing and contract renewal initiation.

  • Payer-provider communication and portals — These tools improve quality by enabling payers and providers to exchange PNM information like provider demographic data (TIN, NPI, office location) and contract and fee schedules.

  • Case and contract management — Technology that helps support collaboration to capture an issue, request or contract and routing to solve a provider problem with provider contract administration. For example, a provider specialty that has been submitted incorrectly.

  • Monitor accreditation and enrollment and compliance — Reporting and dashboard applications that help monitor accreditation and enrollment status to ensure compliance before members can access and engage with providers.

Gartner Research