generated: '2026-09-07' method: derived source: openapi/ (12 first-party Centene OpenAPI documents) + conformance/centene-provider-directory-capabilitystatement.json provider: Centene providerId: centene note: >- Derived from the components.schemas of Centene's published specs and cross-checked against the live FHIR CapabilityStatement. The important structural fact is that Centene does not have one data model - it has two, and they describe the same real-world providers in incompatible ways. The FHIR estate speaks HL7 R4 resources with FHIR reference semantics. The Provider RTR Demographics and PCES estate speaks a bespoke Centene provider model with 151 and 85 schemas respectively and no FHIR mapping published between them. domains: - id: fhir-patient name: Member clinical and financial record (US Core + CARIN BB) spec: openapi/centene-fhir-patient-access-openapi.json entity_count: 24 identity: FHIR logical id; the token response carries a `patient` claim naming the compartment root note: All resources are scoped to the authorizing member's patient compartment. - id: fhir-directory name: Provider directory (Da Vinci PDEX Plan Net 1.2.0) spec: openapi/centene-fhir-provider-directory-openapi.json entity_count: 9 identity: FHIR logical id live_capability_statement: https://iopc-pd.api.centene.com/iopc/pd/fhir/providerdirectory/metadata - id: rtr-demographics name: Provider RTR demographics (bespoke) spec: openapi/centene-provider-rtr-demographics-openapi.json entity_count: 151 identity: Centene provider identifiers (NPI, CAQH, Amisys records, business identifiers) note: >- The richest model in the estate and the only one carrying credentialing, accreditation, contracting and network-participation detail. It shares no schema with the FHIR directory. - id: pces name: Provider Carrier Entity Search (bespoke, search-index shaped) spec: openapi/centene-pces-openapi.yaml entity_count: 85 identity: carrier entity id note: An Elasticsearch-shaped model - aggregations, buckets, bounding boxes, geo coords. - id: edi name: X12 / CAQH CORE transaction envelopes spec: openapi/centene-edi-core-realtime-openapi.json entity_count: 37 entities: - name: Practitioner domain: fhir-directory description: An individual provider. relationships: - to: PractitionerRole type: has_many via: PractitionerRole.practitioner - to: Organization type: belongs_to via: PractitionerRole.organization - to: Location type: has_many via: PractitionerRole.location - name: PractitionerRole domain: fhir-directory description: The join resource binding a practitioner to an organization, location, network and specialty. relationships: - to: Practitioner type: belongs_to via: practitioner - to: Organization type: belongs_to via: organization - to: Location type: has_many via: location - to: HealthcareService type: has_many via: healthcareService - to: Endpoint type: has_many via: endpoint - name: Organization domain: fhir-directory relationships: - to: OrganizationAffiliation type: has_many via: OrganizationAffiliation.organization - to: Location type: has_many via: Location.managingOrganization - to: Endpoint type: has_many via: endpoint - name: OrganizationAffiliation domain: fhir-directory description: Network participation - which organization participates in which network for which plan. relationships: - to: Organization type: belongs_to via: organization - to: Organization type: belongs_to via: participatingOrganization - to: HealthcareService type: has_many via: healthcareService - to: Location type: has_many via: location - name: Location domain: fhir-directory relationships: - to: Organization type: belongs_to via: managingOrganization - name: HealthcareService domain: fhir-directory relationships: - to: Organization type: belongs_to via: providedBy - to: Location type: has_many via: location - name: InsurancePlan domain: fhir-directory description: The plan and network a member is shopping or enrolled in. relationships: - to: Organization type: belongs_to via: ownedBy - to: Organization type: belongs_to via: administeredBy - name: Endpoint domain: fhir-directory description: A technical endpoint for exchanging data with an organization - the PDEX payer-to-payer hook. - name: Patient domain: fhir-patient description: The authorizing member. Root of the patient compartment. relationships: - to: Coverage type: has_many via: Coverage.beneficiary - to: ExplanationOfBenefit type: has_many via: ExplanationOfBenefit.patient - to: Condition type: has_many via: Condition.subject - to: Observation type: has_many via: Observation.subject - to: MedicationRequest type: has_many via: MedicationRequest.subject - to: AllergyIntolerance type: has_many via: AllergyIntolerance.patient - to: Immunization type: has_many via: Immunization.patient - to: CarePlan type: has_many via: CarePlan.subject - to: CareTeam type: has_many via: CareTeam.subject - to: Encounter type: has_many via: Encounter.subject - to: DiagnosticReport type: has_many via: DiagnosticReport.subject - to: Goal type: has_many via: Goal.subject - to: Procedure type: has_many via: Procedure.subject - to: Device type: has_many via: Device.patient - name: Coverage domain: fhir-patient description: The member's enrollment in a Centene plan. relationships: - to: Patient type: belongs_to via: beneficiary - to: Organization type: belongs_to via: payor - name: ExplanationOfBenefit domain: fhir-patient description: Claims and encounters, profiled by CARIN BB 2.0.0. relationships: - to: Patient type: belongs_to via: patient - to: Coverage type: belongs_to via: insurance.coverage - to: Practitioner type: has_many via: careTeam.provider - to: Organization type: belongs_to via: insurer - name: MedicationRequest domain: fhir-patient relationships: - to: Medication type: belongs_to via: medicationReference - to: Patient type: belongs_to via: subject - to: Practitioner type: belongs_to via: requester - name: MedicationKnowledge domain: fhir-patient description: Formulary content, profiled by Da Vinci US Drug Formulary 2.0.1. - name: Provenance domain: fhir-patient description: PDEX provenance - which source system supplied a resource. cross_domain_gaps: - >- There is no published crosswalk between the FHIR directory `Practitioner` and the Provider RTR Demographics provider record, even though both describe the same physician. An integrator consuming both must join on NPI by hand. - >- PCES CarrierEntity has no declared relationship to either FHIR Organization or the RTR business-entity model. - >- Product Mapping V2 returns networks and counties for an address but does not reference InsurancePlan ids from the FHIR directory. identifiers: - name: NPI scope: National Provider Identifier - the only identifier that appears across both the FHIR and bespoke models. - name: CAQH scope: Present in the Provider RTR Demographics model as a credentialing source. - name: FHIR logical id scope: Opaque per-server. Not stable across the general and California Provider Directory deployments. render: null maintainers: - FN: Kin Lane email: kin@apievangelist.com