Provider Network Solutions

What Provider Network Solutions does

Provider Network Solutions (PNS) is a Florida-based value-based specialty Managed Service Organization founded in 1998 by four partners. The company curates and administers multi-specialty provider networks spanning Allergy, Cardiology, Dermatology, Neurology, Nephrology, Orthopedics, Oncology/Hematology, Pain Management, Podiatry, and Pulmonology, connecting board-certified specialists, primary care providers, and health plan partners across Medicare Advantage, Traditional Medicare, Medicaid Managed Care, Healthy Kids, Commercial, and Exchange/ACA lines of business. PNS serves approximately 3.6 million lives through 30+ health plan partnerships including AvMed, Florida Blue, Cigna, Simply Healthcare, and Florida Community Care, with operations based in Miami and Puerto Rico.

The company's integrated operating platform combines a licensed Third-Party Administrator (TPA, via wholly-owned Claims Development Corp.), NCQA-accredited utilization management, HITRUST-certified technology infrastructure (Provider Portal at portal.pns-mgmt.com and Referral Portal), compliance oversight with documented >97% passing score across approximately 30 external CMS audits per year, and a boots-on-the-ground network development and provider relations team. Wholly-owned subsidiaries extend the platform: Spatially Health provides healthcare spatial analytics, Stellae operates a full-risk Primary Care MSO, PNS Puerto Rico handles the Puerto Rico market, and PNS Cares (501c3) anchors community engagement.

PNS generates revenue primarily through contracted network access fees paid by health plans (per-member-per-month and per-claim administrative arrangements), third-party administration services, utilization management fees, and credentialing services, with multi-year contract structures and evergreen provider agreements. The company sells via enterprise field sales teams targeting health plans alongside in-house provider-recruitment activity, complemented by a self-serve Provider Portal for ongoing servicing.

Name

Provider Network Solutions

Legal name

Provider Network Solutions LLC

Website

https://providernetworksolutions.com

Company type

Private

Founded year

1998

Operating status

Operating

Headcount range

101–250 employees

Short description

Provider Network Solutions is a Florida-based value-based specialty Managed Service Organization operating an integrated TPA, utilization management, credentialing, and specialty provider network platform serving health plans, primary care providers, and specialists across Medicare, Medicaid, and Commercial lines, covering 3.6 million lives in Florida and Puerto Rico.

Ownership category

akta.pro rank

Product category

Specialty Healthcare Network Management Services

SIC

Services-Health Services (8000)

akta.pro primary industry

Provider Network Administration & Contracting (PPO Network Management) (HLAEALAE)

akta.pro secondary industries

Provider Network & Care Management for Commercial Members (HLAEAAAL), Medicare Provider Networks & Delegated Medical Groups (MA-focused) (FSAIAGAK), Provider Network, Credentialing & Contracting Support (BPAAAFAI), Managed Care / Network-Based Group Health Plans (Carrier Network Products) (FSAIAFAO)

Keywords

• Healthcare network management
• Specialty care management
• Third party administration
• Provider network services
• Utilization management

Headquarters

HQ city

Miami

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure

Revenue model

1. Network Access Fees: Health plans pay for access to PNS's network of board-certified specialists and primary care providers. Revenue derived from per-member-per-month (PMPM) arrangements or per-claim administrative fees negotiated in network contracts.
2. Third-Party Administration (TPA) Services: Claims processing services through Claims Development Corp. (iTPA), handling Medicare, Medicaid, Healthy Kids, CMS T19 & T21 & Commercial lines of business with integrated TPA system
3. Utilization Management Services: NCQA Accredited utilization management ensuring appropriate, cost-effective, highest quality healthcare delivery under managed care contracts
4. Credentialing Services: Credentialing intake aligned with NCQA guidelines and health plan partners' credentialing requirements, alleviating initiating process for unqualified providers

Pricing tiers

Go-to-market motion2 records

Distribution channels5 records

Marketing channels7 records

Core offering

Provider Network Solutions is a Value-Based Specialty Care Managed Service Organization that builds and operates specialty provider networks of board-certified physicians and delivers delegated managed-care services to health plans, primary care providers, and specialists across Florida and Puerto Rico. Core contracted deliverables include Third-Party Administration (claims processing for Medicare, Medicaid, Healthy Kids, and Commercial lines), NCQA-accredited utilization management, network development and credentialing intake, provider relations, and compliance oversight (~3.6 million lives served).

Product overview

Provider Network Solutions (PNS) operates as a Value-Based Specialty Organization and Managed Service Organization providing an integrated suite of healthcare management services. The portfolio consists of core administrative services including Claims Processing (TPA), Network Development, Provider Relations, Utilization Management, Credentialing Intake, and Compliance Oversight. These are supported by technology platforms including the Provider Portal (eligibility verification, claims status, EOP access, EFT setup), Referral Portal (HITRUST certified, for PCP-to-specialist referrals), and Electronic Claims Submission/EFT systems. PNS delivers specialty care management across multiple lines of business (Medicare, Medicaid, Healthy Kids, Commercial, Exchange/ACA) through specialty networks covering Allergy, Cardiology, Dermatology, Neurology, Nephrology, Orthopedics, Oncology/Hematology, Pain Management, Podiatry, and Pulmonology. The company's corporate citizenship initiative is branded as PNS Cares (501c3). The integrated ecosystem connects Health Plans, Primary Care Providers, and Specialty Care Providers serving approximately 3.6 million lives in Florida and Puerto Rico.

Differentiator

Problem solved

Functional benefit

Brands

• PNS Cares: Non-profit corporate citizenship organization (501c3) focused on empowering employees to improve their communities by spreading hope and sharing love with those less fortunate.

Products and services

• Claims Processing (Third-Party Administration) A fully licensed and integrated Third-Party Administrator (TPA) system that processes claims for Medicare, Medicaid, Healthy Kids, CMS T19 & T21, and Commercial lines of business for health plan partners via wholly owned subsidiary Claims Development Corp. (iTPA).
• Network Development Specialty network development service that ensures all state and federal guidelines for member access, accessibility, and provider ratio count are met, building specialty networks of Board-Certified and Board-Eligible Physicians for health plan partners.
• Provider Relations Boots-on-the-ground field service that partners with health plans, providers, and the community to deliver personalized specialty care solutions, including dedicated provider servicing, designated office representatives, and field visits.
• Utilization Management NCQA Accredited utilization management service ensuring healthcare delivery is appropriate, cost-effective, and of the highest quality under managed-care contracts, with Specialty Medical Director support.
• Credentialing Intake Credentialing intake service aligned with NCQA guidelines and Health Plan partners' credentialing requirements, providing a single credentialing process for providers across all contracted health plans.
• Compliance Oversight Compliance oversight of all CMS Medicare, Medicaid, and health-plan requirements, with overall passing score greater than 97% on an average of 30 External Audits per year (CY2022 data).
• Specialty Networks Multi-specialty provider networks covering Allergy, Cardiology, Dermatology, Neurology, Nephrology, Orthopedics, Oncology/Hematology, Pain Management, Podiatry, and Pulmonology, connecting contracted specialists to multiple payors for approximately 3.6 million lives with geographic exclusivity where available.
• Specialty Care Management Value-based specialty care management service supporting Primary Care Providers' financial models through aligned specialist networks, transparent reporting, compliance updates, and quality clinical care coordination.
• Provider Portal Self-service web portal at portal.pns-mgmt.com offering instant eligibility verification, claim-status checks, Explanation of Payment (EOP) access, and Electronic Funds Transfer setup for contracted providers.
• Referral Portal HITRUST certified referral portal enabling Primary Care Providers to guide specialty referrals appropriately with support from Specialty Medical Directors, with strong focus on the security of members' Protected Health Information.
• Electronic Claims Submission Electronic claims submission service via Payer ID 43056 supporting Medicare (30-day processing), Medicaid & Healthy Kids (20-day electronic / 30-day paper), and Commercial (20-day electronic / 30-day paper) claims.
• Electronic Funds Transfer (EFT) Electronic Funds Transfer service enabling seamless payment processing for provider services through secure account setup, integrated with the Provider Portal.

Quantifiable outcome

• 3.6 million lives served through specialty networks
• +4 more outcomes

Named customers7 records

Segments3 records

Ideal customer profiles3 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Feature5 records

Partnerships

22 partnerships are on record, tiered core, supporting and minor.

• Claims Development Corp. (iTPA)coreImplementation/ SI/ Consulting PartnerLicensed and integrated Third Party Administration (TPA) providing claims processing services for Medicare, Medicaid, Healthy Kids, CMS T19 & T21 & Commercial lines of business
• PNS Puerto RicocoreStrategic or Co-development PartnerHealthcare management ecosystem in Puerto Rico extending PNS's geographic footprint and specialty network capabilities to Puerto Rico market
• Spatially HealthcoreTechnology or IntegrationHealthcare Spatial Analytics Solutions company providing health care analytics capabilities as a strategic technology partner
• StellaesupportingStrategic or Co-development PartnerPart of PNS strategic solutions ecosystem providing innovative points-of-service clinical solutions
• HOPCosupportingStrategic or Co-development PartnerHealthcare outcomes and performance optimization partner included in strategic solutions portfolio
• Wound SolutionssupportingStrategic or Co-development PartnerWound care specialty solutions partner within the strategic solutions ecosystem
• NCQA Accredited Utilization Management OrganizationcoreStrategic or Co-development PartnerNCQA Accredited Healthcare Utilization Management partner providing compliance oversight and quality clinical initiatives distinguishing PNS from competitors
• AvMedcoreChannel Partner/ Reseller/ DistributorHealth plan partner requiring authorization for MOHS surgery; covers PDT treatment for AvMed members
• Florida BluecoreChannel Partner/ Reseller/ DistributorMajor health plan partner in Florida market; covers PDT treatment for Florida Blue members
• Simply HealthcaresupportingChannel Partner/ Reseller/ DistributorHealth plan partner included in network contracting for specialty services
• CignasupportingChannel Partner/ Reseller/ DistributorHealth plan partner included in network contracting for specialty services
• Florida Community CaresupportingChannel Partner/ Reseller/ DistributorHealth plan partner in Florida market included in specialty network services
• National MS SocietyminorOthersSupporting Walk MS: Miami 2026 event for families impacted by Multiple Sclerosis
• Kiwanis InternationalminorOthersPartnership for Back To School Drive helping students with essential school supplies
• 100 Black Men of South FloridaminorOthersPartnership for Thanksgiving Food Drive providing food donations to families
• Big Brothers Big SistersminorOthersFoundation supported through PNS Cares corporate citizenship program
• Feeding FloridaminorOthersFood bank network supported through PNS Cares charitable initiatives
• Health Foundation of South FloridaminorOthersFoundation supported through community health initiatives and PNS Cares program
• JDRFminorOthersType 1 diabetes research foundation supported through PNS Cares donations
• Stand Up To CancerminorOthersCancer research foundation supported through PNS Cares charitable donations
• Toys for TotsminorOthersHoliday Toy Drive partnership bringing joy to children and families through donations
• West Kendall Baptist HospitalminorOthersHealthcare foundation supported through community health initiatives

Scale indicators7 records

Recent moves6 records

Expansion highlights6 records

Broad incumbents

• Aptarro (formerly Availity): Availity operates a large healthcare information network connecting payers, providers, and technology vendors for eligibility, claims, and prior authorization. While it is more of a clearinghouse and interoperability platform than a delegated MSO, its provider portal and workflow tools overlap with PNS's HITRUST-certified provider and referral portals.
• MultiPlan: MultiPlan is the largest independent provider of PPO network and cost-management services in the U.S., serving payers with network access, claims cost containment, and analytics. Comparable to PNS as both monetize via per-member network access and PPO network leasing to commercial, Medicare, and Medicaid plans, though MultiPlan operates nationally at vastly larger scale.
• Zelis: Zelis provides healthcare network management, claims cost management, and integrated payments to payers and providers. Like PNS, it generates revenue from network access fees and claims-adjacent services; Zelis is a much larger, private-equity-backed incumbent operating across all U.S. states.
• EviCore (Evernorth): EviCore, part of Cigna's Evernorth health services segment, is a leading utilization management and specialty care management organization serving health plans and providers. Both PNS and EviCore compete in NCQA-accredited UM, prior authorization, and specialty referral management, though EviCore operates nationally and is owned by a major payer.

Direct peers

• New Century Health: New Century Health provides specialty care management and value-based oncology and cardiology programs for health plans and providers. It is a close functional peer to PNS's specialty network and UM offering, particularly in cardiology and oncology value-based arrangements.
• HealthSmart (HealthSmart Holdings): HealthSmart is a PPO network, third-party administrator, and managed care services company offering claims processing, network leasing, and utilization management. It mirrors PNS's combination of TPA, network access, and UM under one umbrella.
• Prime Health Services: Prime Health Services is a PPO and specialty network provider offering network access, claims repricing, and case management. It directly competes with PNS for health plan network leasing relationships and serves similar workers' comp, group health, and auto/PIP lines.
• AIM Specialty Health (Evernorth): AIM Specialty Health, a sister Evernorth company to EviCore, provides specialty utilization management for radiology, oncology, cardiology, and other specialties. Both PNS and AIM compete for the same health plan UM contracts and serve the same specialty physician base.
• Stratose (formerly Coalition America): Stratose operates a national PPO network and provides claims cost management, network access, and provider contracting services. It is a direct competitor in the carrier-network product and specialty network leasing categories PNS serves.

Regional players

• Galaxy Health Network: Galaxy Health Network operates a PPO-style provider network offering network access and ancillary services to payers and TPAs. Comparable to PNS as a regional network operator leveraging NCQA-aligned credentialing and provider contracting, but with a different geographic footprint.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat5 records

Key risks6 records

Key highlights6 records

Customer concentration

• Facebookfacebook.com/Provider-Network-Solutions-LLC-154973637876690
• LinkedInlinkedin.com/company/providernetworksolutions

Compliance4 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles12 records

Subsidiaries5 records

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Provider Network Solutions