Screen Catalog — provider library

Significant windows in the provider library. Every window that maintains segment-scoped data validates the user's client segment on open and shows it in the title ("... for Segment: name (code)") (provider/u_provider_sql.of_validate_client_segment).

w_provider_maintenance — "Provider Maintenance"

Purpose: create and maintain providers with all identifiers, addresses, network panels and holds (provider/w_provider_maintenance, PBExportComments "Maintenance window for providers").

Search header: TIN (9-digit mask; EIN/SSN radio), Name (last/company vs Lookup-name radio, "Sounds Like" soundex checkbox), Provider Type, Specialty, City, State, status checkboxes Active/Inactive/Potential (default Active). At least one criterion and one status is required; >200 matches prompts before listing; multiple matches open w_provider_select_urcm; zero matches (Active included, provider-dept user) starts a new provider.

Tabs and field groups:

Tab	DataWindow(s)	Fields
Provider	d_provider	Status, Company Name, Provider Name (title/first/middle/last), Lookup Name, Birthdate, Educational Degree, Primary Specialty, Clearinghouse Number, UPIN, Medicare Number, Provider Type, Languages, After Hours contact info, System ID, Covering Provider (search button → w_provider_select_urcm), Default Vendor (search button → w_provider_vendor_select), General Comments
Provider (sub-lists)	d_tin, d_medicaid, d_provider_npi, d_specialty	TINs (type EIN/SSN + number), Medicaid IDs (state + id), NPIs, Specialties
Addresses	d_provider_address, d_provider_address_vendor, d_provider_contacts	Address (addr1/2, city, state, zip via pm_addresses, standardized flag), contact (name, phone, fax, email, position, comments via pm_contacts), and per-address dated vendor list with Add-Vendor search (name/TIN)
Panels	d_provider_hcn, d_provider_panel	HCN search/add ("Add HCN" name search → w_provider_hcn_select), panel rows per HCN: panel, eff/exp dates, exp reason
Holds	d_provider_holds	Start date, hold reason (PRVDHOLD), end date, end-date type (PRVDHOLDDT)
Group Holds	d_provider_group_holds	Group id, hold reason (PROVGRPHLD), start/end dates

Validations: see PRV-1..PRV-10 (index page). Save is a single transaction with address standardization and duplicate-address rejection (pfc_save).

Actions / windows opened: w_provider_select_urcm, w_provider_vendor_select, w_provider_hcn_select, w_provider_tin_enter and w_provider_tin_select (default vendor creation), notes service (n_notes). Menu m_provider_maintenance_menu adapts add/delete availability per tab and per mode (PROVIDER / UM / OTHER).

Guide notes: this window implements the PMDE (Provider Maintenance Data Entry) specification of User Guide ch. 7 (built by StarTech for SFPI on PowerBuilder 6.5/Oracle 7). The guide explains the URCM naming: provider records added through the UR/CM interface are "not live" and must be excluded from normal processing until promoted — matching the Potential status workflow of UM-created providers (PRV-4). It also specifies address behavior the code confirms: deleting a provider address only removes the association (a database trigger deletes the pm_addresses row when nothing else references it), and editing an address shared by multiple providers must prompt whether to change it for all or only this one (User Guide ch. 7).

w_provider_vendor_maintenance — "Vendor Maintenance"

Purpose: maintain payees (vendors) with addresses, contacts, holds, and status (provider/w_provider_vendor_maintenance).

Field groups: vendor header (d_provider_vendor: System ID, Name, Lookup Name, TIN + type EIN/SS#, Status, Payment Rule Claimed/Incurred/Received + rule date, Produce 1099? Y/N); addresses (d_provider_vendor_address, dated with exp reason VNDRADDRXR); contacts (d_provider_vendor_contact, contact type required); holds (d_provider_vendor_holds: start date, reason VNDRHOLD, end date + end-date type); status history (d_provider_vendor_status).

Validations: name, lookup name and TIN required; at least one address; address date rules; hold rules (see PRV-11/PRV-12).

Guide notes: the Payment Rule + date indicate how many days to wait before paying an adjudicated claim and which claim date anchors the wait; a vendor can have only one active address and one active hold at a time (date overlap blocked by database triggers). The guide additionally requires at least one contact per vendor (User Guide ch. 7) — the extracted validations enforce contact type only on entered rows, not a minimum of one; discrepancy for SME confirmation.

w_provider_hcn_maintenance — "HCN Maintenance"

Purpose: maintain Health Care Networks and their network-level withholds, contacts and pricing plans (provider/w_provider_hcn_maintenance).

Field groups: HCN tab (d_hcn): ID, Name, EOB Description (reason code), Eligibility File Format (census format), Code Review? Y/N, Type HMO / HMO-PPO / PPO, Automatic Contract Insertion Y/N, Automatic Provider Insertion Y/N, Reject Non-Reprice Sheets Y/N, Electronically Paid Y/N. Withholds tab (d_hcn_withhold): vendor (search → w_provider_vendor_select), withhold % (≤100), type Allowed/Paid, dated with exp reason. Contacts tab (d_hcn_contact + d_provider_contacts, standardized addresses with "update all HCNs at this address" prompt). Pricing tab (d_hcn_pricing): dated pricing-plan rows; "select plan" button opens pricing/w_pricing_plan_maintenance_single.

Actions: New HCN defaults (type PPO, code review N, default HCN reason); hard delete with child cleanup and FK-block message; save validated per tab (PRV-15..PRV-19).

Guide notes: the two automatic-insertion switches apply only to claims arriving as reprice sheets — the Corrections background process consults them to auto-add provider contracts (Automatic Contract Insertion) and providers (Automatic Provider Insertion); normal claims are unaffected (User Guide ch. 7). Code Review Y/N tells the rest of the system whether the network's claims run through Code Review. HCN-level withholding defaults to off (contract and panel levels default on); an HCN may have only one withhold per vendor at a point in time (User Guide ch. 7; see PRV-49).

Contact types are the HCN's addressing model. The guide requires seven contact types at HCN level — Provider Relations, Customer Service, UR Department, Pricing, Sales, MIS, Claims — and states that HCN addresses "may only be accessed through the contacts table": unlike providers, which have direct access to an address (and can also reach one via a contract), an HCN has no direct address at all. Provider level requires exactly one contact type ("Provider Contact") and vendor level one ("Vendor Contact"). The Pricing contact is the one repricing follow-ups are sent to, and an examiner message is raised when an HCN has none (User Guide ch. 7, ch. 12; see index Open questions #8). The extracted d_hcn_contact carries contacts without enforcing this type list — a gap to close or consciously drop in migration.

w_provider_panel_maintenance — "Provider Panel Maintenance"

Purpose: maintain panels within an HCN, with panel-level withholds and pricing plans (provider/w_provider_panel_maintenance; tables panels, panel_withholds, panel_pricing).

Validations: panel ID + name + effective date required; expiration after effective + reason (PANELXRSN); withhold vendor/pct(≤100)/type/dates within panel dates; pricing plan + effective date (PRV-18..PRV-20).

w_provider_contract_maintenance — "Provider Contract Maintenance"

Purpose: maintain per-provider network contracts with per-contract withholds, holds and pricing plans (provider/w_provider_contract_maintenance).

Field groups (d_contracts, one contract per page with scrollbar): HCN, Contract Type (Payable/Capitated/Staff/Fund), Remittance Advice Format (EOB, EOB/EOB, EOB/RA, EDI, Custom, None), Effective/Expiration dates + Expiration Reason (CNTRCTXRSN), Network Provider ID, Enrollment Limit, PCP? Y/N, New Patients Allowed? Y/N, Withholds Allowed? Y/N, DRG Hospital Multiplier, DRG Cap Rate, Capitation Vendor (search → w_provider_vendor_select). Provider located via the same search header as provider maintenance.

Validations: PRV-22/PRV-23; per-contract withhold/hold/pricing validation loops filtered by contract_sys_key (ue_validate).

Guide notes: the DRG Hospital Multiplier and DRG Cap Rate feed the DRG pricing formula — base DRG amount = DRG weight × hospital multiplier + CAP rate, hospitals only, both values date-varying (User Guide ch. 12). Contract type values originate from the legacy Diamond system; a contract defines the 1:1 provider-to-HCN relationship that must exist before any panel membership in that HCN, and a provider may hold only one contract per HCN at a point in time (trigger-enforced, PRV-50). The guide-era RA formats were "Standard, EDI, None" — the six current values (PRV-22) are a later evolution. Contract-level pricing overrides HCN-level pricing; panel-level overrides both (User Guide ch. 7). The Enrollment Limit, PCP and New Patients fields are validated by the enrollment module when a member selects a PCP (User Guide ch. 7, interface modifications).

w_provider_select_urcm / w_provider_select — "Select Provider"

Purpose: result pick lists for provider searches; w_provider_select_urcm receives the dynamically built SQL/sys-key list from u_provider_sql.of_count_providers_urcm; w_provider_select is the older TIN/company/last-name selector used by other domains (provider/w_provider_select PBExportComments). Both return provider sys key + name; the URCM variant can also return "new" to trigger provider creation.

w_provider_vendor_select — "Select Vendor"

Purpose: vendor pick list by TIN/name/status used for default vendor, withhold vendor and capitation vendor selection (opened from provider, HCN, panel and contract windows; counts via u_provider_sql.of_count_vendors).

w_provider_hcn_select — "Select HCN"

Purpose: HCN pick list by name within segment (opened from provider maintenance panels tab; counts via u_provider_sql.of_count_hcns).

w_provider_tin_enter / w_provider_tin_select

Purpose: capture a TIN (with EIN/SSN type) or choose among a provider's multiple TINs when auto-creating the default vendor (provider/w_provider_maintenance ue_create_default_vendor).

w_1099_print — "Print 1099 Forms"

Purpose: filter and print vendor 1099/1099-NEC forms from print_1099s (provider/w_1099_print).

Fields: filter row (d_1099_filter): group id, tax year, vendor TIN, original print date range, last print date range, printed indicator; results grid d_1099_print_select (multi-select, sortable).

Actions: print selected → renders d_1099_form (or d_1099nec_form for group 501-069Z); reprints prompt for a reason via w_1099_reason; rows updated with printed flag/dates and committed. 147c/W-9 request letters exist as DataWindows (d_147c_request, d_w9_request, d_w9_request_2) — these belong to CP2100 processing (IRS TIN-mismatch notices): d_w9_request requests a W-9, d_w9_request_2 is sent as the result of a hold on the vendor, and d_147c_request is sent when the IRS requires the vendor to obtain a 147c letter; each letter takes the vendor sys key and the focused contact from Vendor Maintenance (User Guide ch. 7). The guide also states 1099 dollars are not accumulated as payments are made but calculated at year end when forms are produced, and that 1099s are issued per vendor per client (see index Open questions #6).

w_provider_consolidate_vendors — "Consolidate Vendors"

Purpose: merge duplicate vendors on a TIN; user marks the surviving "main vendor"; duplicates are snapshotted to consolidated_vendors and all references repointed (contracts, provider address vendors, fund register payees, default vendors), children deleted (provider/w_provider_consolidate_vendors ue_consolidate).

w_hcn_enrollment_dump — "Health Care Network Enrollment Dump"

Purpose: produce PPO census/eligibility files per HCN in the network's census format (generic, Cigna, Emerald, HFN, HS, MMO, VSP writers n_hcn_dump_*; selection DataWindows d_hcn_dump_select, d_ppo_group_selected, d_ppo_enrollment_selected, d_ppo_census). Menu m_hcn_enrollment_dump.

Operation (User Guide ch. 7): one client segment per session; HCNs are filtered into same-format lists so a file mixes only one format. Three steps: highlight the HCNs, "Load PPO Tables" (stages into ppo_enrollment_work / ppo_group_work, viewable via View Table radios), then "Export To TXT File" (reports record count and file name). The "Remove all members who are termed more than 6 months" checkbox must be set before loading. Output names are format prefix + 'MMDDYYhhmm' (e.g. GEN1110001042.TXT); files are archived, zipped, and delivered monthly per network over per-HCN channels (PGP-encrypted FTP/SFTP/email), each with a delivery log. The generic layout is fixed 160-byte "R" (employer) and "E" (employee/member) records with an N/C/T activity flag; instructions for reading it accompany the first file sent to a new network.

w_edi_partners / w_edi_partners_select — "EDI Trading Partners"

Purpose: maintain outbound-EDI repricing trading partners (outbound_edi_trading_partners: id, name, partner type EDIPARTNER, clearinghouse, routing number, allowance days, pay-by days, retention days, no-reply action EDIACTION, status) and their contacts (outb_edi_tradingpart_contacts) (provider/w_edi_partners, provider/d_edi_trading_partners, d_edi_trading_partner_contacts).

w_edi_clearinghouse / w_edi_clearinghouse_select — "EDI Clearinghouse Maintenance"

Purpose: maintain EDI clearinghouses (outbound_edi_clearinghouses) and contacts (outb_edi_clearhouse_contacts) (provider/w_edi_clearinghouse).

w_provider_open_cant_find_provider_msgs — "Open Provider Messages"

Purpose: work queue of open "cannot find provider" claim messages produced when automatic provider matching fails, so provider staff can create/fix providers (provider/w_provider_open_cant_find_provider_msgs, d_provider_open_cant_find_provider_msgs; producer clmshare/n_provider_maintenance.of_find_provider).

w_unsearchable_tins — "Unsearchable Tins"

Purpose: maintain the list of TINs excluded from automatic matching (unsearchable_tins) (provider/w_unsearchable_tins).

w_provider_change_segment / w_provider_segment_user_maintenance / w_provider_segment_group

Purpose: switch the user's active client segment (response window), maintain which users belong to which client segments (client_segment_users; d_provider_segment_user_maintenance, d_provider_users), and segment-group linkage (provider/w_provider_change_segment, w_provider_segment_user_maintenance, w_provider_segment_group).

w_provider_specialties / w_provider_types_maintenance — reference data

Purpose: maintain the specialty list (specialties, including anesthesia indicator) and provider types (provider_types) (provider/w_provider_specialties, w_provider_types_maintenance, d_specialties_maintenance, d_provider_types_maintenance).

w_provider_rpt_hcn_pricing_methods — HCN pricing methods report

Purpose: as-of-date report of HCN → plan package pricing logic → group, joining group_coverages, plan_pkgs, health_care_networks, groups (Medical coverages, segment SFPI) (provider/w_provider_rpt_hcn_pricing_methods, d_provider_rpt_hcn_pricing_methods).

w_provider_caremark_flag_transfer / w_provider_optum_flag_transfer

Purpose: produce PBM (Caremark / Optum) eligibility flag files with deductible/OOP variants; audited via caremark_report_audit / optum_report_audit (provider/w_provider_caremark_flag_transfer, w_provider_optum_flag_transfer, d_caremark_flag_*, d_optum_flag_*). Peripheral to provider mastering; included for inventory completeness.

w_hms_reporting / w_hms2 — "HMS REPORTING"

Purpose: ad-hoc HMS export/reporting over enrollment (worksheets d_hms_export_worksheet*, date selection d_hms_dateselect) (provider/w_hms_reporting, w_hms2). Ownership unclear — see Open questions.

w_provider_group_select — group pick list (response popup)

Purpose: generic selector that lets the user choose an employer group; returns the chosen group_id to the calling screen (provider/w_provider_group_select, DataWindow d_provider_group_select).