> ## Documentation Index
> Fetch the complete documentation index at: https://mso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.

# How to use the payer reference

> Payer, plan, network, and TPA disambiguated; how the profile pages are structured; and how to find any payer's ID, portal, and enrollment forms.

This section covers payer-specific operational detail. Before using it, get the vocabulary right — payer, plan, network, and administrator are four different things — and conflating them produces wrong answers about who owes you money and which law applies.

## The four things

| Term                        | What it is                                                              |
| --------------------------- | ----------------------------------------------------------------------- |
| **Payer**                   | **Any entity that pays claims.** Not synonymous with insurance company. |
| **Plan**                    | The specific benefit design a member bought                             |
| **Network**                 | The set of providers with contracted rates                              |
| **Administrator (TPA/ASO)** | An entity processing claims **without bearing risk**                    |

One payer offers many plans. One plan uses one or more networks. And an administrator's name on a card tells you nothing about who bears the risk.

**The distinction that matters most: fully-insured versus self-funded.**

On a **fully-insured** plan, the insurance company bears the risk. On a **self-funded** plan, the dominant model for large employers, the employer bears the risk and the carrier is only an administrator.

The card looks identical. What differs is the governing law: self-funded employer plans are governed by **ERISA**, with state insurance law largely preempted. That means your state's prompt-pay statute and external review process may simply not apply to a large fraction of your commercial claims.

**Determine funding status before you escalate or cite a state statute.** See [Payers vs insurance companies](/concepts/payments/payers-vs-insurance-companies).

## How the profile pages are structured

Every payer profile follows the same template, so you can navigate any of them blind:

| Section                          | Contains                                        |
| -------------------------------- | ----------------------------------------------- |
| **Who they are**                 | Corporate structure, scale, lines of business   |
| **Plan types you'll see**        | What's on the card                              |
| **Enrollment and credentialing** | Process and links                               |
| **EDI payer IDs**                | Including professional vs institutional gotchas |
| **ERA and EFT setup**            | The path, and whether CAQH EnrollHub applies    |
| **Portal capabilities**          | What you can do without calling                 |
| **Timely filing**                | Default, with the contract-overrides warning    |
| **Appeals**                      | Levels and process                              |
| **Quirks billers know**          | The things that cost you time                   |
| **Specialty notes**              | Dental, vision, behavioral carve-outs           |

## Finding a payer's ID, portal, and forms

<Steps>
  <Step title="Payer ID, use your clearinghouse's payer list">
    **Payer IDs are clearinghouse-specific.** The same payer can have different IDs at different clearinghouses, and separate IDs for professional versus institutional claims. Your clearinghouse's published payer list is the canonical source, not a third-party table, and not this site.

    This is also why switching clearinghouses requires remapping every payer.
  </Step>

  <Step title="Portal, start at the payer's provider site">
    Many payers use **Availity** as their provider portal even when Availity is not your clearinghouse.
  </Step>

  <Step title="Enrollment forms, the payer's provider enrollment page">
    See [Payer enrollment and submission links](/reference/payers/enrollment-links) for the index.
  </Step>

  <Step title="Medical policies and companion guides, the payer's own documentation">
    **These outrank any third-party summary, including this one.** A payer's published medical policy is what you cite in an appeal.
  </Step>
</Steps>

## The payer landscape in brief

| Category                 | Who                                                                                         |
| ------------------------ | ------------------------------------------------------------------------------------------- |
| **National commercial**  | UnitedHealthcare, Elevance, Aetna/CVS, Cigna, Humana                                        |
| **The Blues**            | \~30 **independent licensee companies**, a contract with one is not a contract with another |
| **Integrated**           | Kaiser Permanente, you generally won't bill them for routine care                           |
| **Medicaid MCOs**        | Centene brands, Molina, national carriers' Medicaid arms, regional nonprofits               |
| **Government**           | Medicare FFS (via MACs), Medicare Advantage, Medicaid, TRICARE, VA Community Care           |
| **Non-health**           | Workers' compensation, auto/PIP                                                             |
| **Networks, not payers** | MultiPlan and other rental networks                                                         |

See [The US payer landscape](/concepts/payments/the-payer-landscape).

## Enrollment priority

<Steps>
  <Step title="Identify actual market share in your area">
    Not nationally. In most markets the local Blue is the largest commercial payer.
  </Step>

  <Step title="Start Medicare and Medicaid first">
    Slowest, and no contract negotiation.
  </Step>

  <Step title="Then the largest commercial payer in your market" />

  <Step title="Check panel status before investing months">
    "Panel closed" is a real answer.
  </Step>

  <Step title="Request the fee schedule before signing anything" />
</Steps>

## The multi-entity multiplier

Everything in this section is **per entity**. Each PC is a separate Tax ID with its own contracts, its own credentialing, and its own EDI, ERA, and EFT enrollments with every payer.

|                         | 1 PC × 8 payers | 10 PCs × 8 payers |
| ----------------------- | --------------- | ----------------- |
| Contracts               | 8               | 80                |
| EDI/ERA/EFT enrollments | 24              | 240               |

This is why clearinghouse **enrollment support quality** is the criterion worth weighting most heavily. See [Choose a clearinghouse](/guides/billing/choose-a-clearinghouse).

## A standing caveat on these pages

**Payer content ages fastest of anything on this site.** Portals move, forms change, payer IDs get reassigned, and **timely filing limits are contract-specific regardless of what any table says**.

Treat these pages as orientation. The payer's own current documentation and **your own executed contract** are authoritative.


## Related topics

- [The US payer landscape](/concepts/payments/the-payer-landscape.md)
- [Payers vs insurance companies (they're not synonyms)](/concepts/payments/payers-vs-insurance-companies.md)
- [Enroll and contract with commercial payers](/guides/enrollment/enroll-with-commercial-payers.md)
- [Set up EDI, ERA, and EFT with each payer](/guides/enrollment/set-up-edi-era-eft.md)
- [Payer enrollment & submission links](/reference/payers/enrollment-links.md)
- [Timely filing limits by payer](/reference/payers/timely-filing-limits.md)