Payers Glossary · Health Tech

Accumulator: a member's running total toward a deductible, out-of-pocket maximum, visit limit or dental maximum for a benefit period, kept as a ledger of entries per claim line (Inside a Payer).
Accumulator adjustment program: a plan or PBM rule that manufacturer copay assistance does not count toward the member's deductible or out-of-pocket maximum (Pharmacy Benefits & PBMs).
Adjudication: the payer's processing of a claim through edits, eligibility, network, benefits, coding, pricing and cost-sharing to a paid or denied result; reprocessing adds a new adjudication (Inside a Payer).
Auto-adjudication: a claim adjudicated with no human touch; the core admin vendors' headline metric (Inside a Payer).
CAQH ProView: the shared credentialing profile a practitioner enters once and shares with the plans they designate; CAQH rebranded as DataSpring in 2026 (Credentialing, Enrollment & Provider Data).
Coinsurance: the member's percentage share of the allowed amount after the deductible (Payers & Plans).
Copay: a fixed amount the member pays per service type, often outside the deductible (Payers & Plans).
Credentialing: a payer's verification of a practitioner's licenses, training, history and sanctions from primary sources, with a committee decision and recredentialing on a cycle (Credentialing, Enrollment & Provider Data).
Deductible: what a member pays each benefit period before the plan pays, individual or family, embedded or aggregate (Payers & Plans).
ERISA: the federal law governing private employer benefit plans; it preempts state laws relating to self-funded plans while saving state insurance regulation of insurers (Payers & Plans).
Formulary: a plan's list of covered drugs, in tiers, with prior authorization, step therapy and quantity limits, versioned through the year (Pharmacy Benefits & PBMs).
LEIE (List of Excluded Individuals/Entities): the HHS OIG list of parties excluded from federal health care programs, whose items and services federal programs won't pay for (Credentialing, Enrollment & Provider Data).
MAC (Medicare Administrative Contractor): the regional contractor that processes Medicare Part A and B claims for a jurisdiction, or DME claims (Payers & Plans).
Medical loss ratio: the share of premium an insurer must spend on medical care (80% or 85% by market) or rebate (Payers & Plans).
Medicare Advantage: private plans paid per member by CMS that replace traditional Medicare Parts A and B for members who choose them; 55% of eligible beneficiaries in 2026 (Payers & Plans).
Network: the set of providers contracted to accept a payer's rates for a plan; participation is per practitioner, location and date (Payers & Plans).
Out-of-pocket maximum: the most a member pays in a benefit period for in-network covered care; $10,600 individual and $21,200 family for 2026 Marketplace plans (Payers & Plans).
Payer enrollment: loading a practitioner into a payer's system to be paid under a TIN at a location in a network from an effective date (Credentialing, Enrollment & Provider Data).
PBM (pharmacy benefit manager): the company that runs a plan's drug benefit: pharmacy network, formulary, rebates and real-time pharmacy claims (Pharmacy Benefits & PBMs).
PECOS: CMS's online Medicare enrollment system for providers and suppliers (Credentialing, Enrollment & Provider Data).
Provider Access API: the CMS-0057-F FHIR API giving in-network providers with a treatment relationship a member's claims, clinical and prior authorization data, required from January 1, 2027 (Inside a Payer).
Provider directory: a plan's public list of in-network providers, verified at least every 90 days and updated within 2 business days under the No Surprises Act (Credentialing, Enrollment & Provider Data).
Real-time benefit check: a query at prescribing time for a drug's coverage, prior authorization need and estimated cost-share, with alternatives, on NCPDP RTPB (Pharmacy Benefits & PBMs).
Rebate: a manufacturer's payment to a PBM for formulary position, arriving months after the claim (Pharmacy Benefits & PBMs).
Self-funded plan: an employer plan that pays claims from the employer's own money, administered by an insurer or TPA; 67% of covered workers in 2025 (Payers & Plans).
Spread pricing: a PBM charging the plan more for a claim than it pays the pharmacy and keeping the difference (Pharmacy Benefits & PBMs).
TiC (Transparency in Coverage) files: the machine-readable in-network rate and out-of-network allowed amount files plans must post publicly since July 1, 2022, revised by an October 2026 final rule (Inside a Payer).
TPA (third-party administrator): a company that processes claims for a self-funded plan without bearing the risk (Payers & Plans).
Utilization management: a payer's review of medical necessity before, during or after care: prior authorization, concurrent and retrospective review (Inside a Payer).

Accumulator: a member's running total toward a deductible, out-of-pocket maximum, visit limit or dental maximum for a benefit period, kept as a ledger of entries per claim line (Inside a Payer).
Accumulator adjustment program: a plan or PBM rule that manufacturer copay assistance does not count toward the member's deductible or out-of-pocket maximum (Pharmacy Benefits & PBMs).
Adjudication: the payer's processing of a claim through edits, eligibility, network, benefits, coding, pricing and cost-sharing to a paid or denied result; reprocessing adds a new adjudication (Inside a Payer).
Auto-adjudication: a claim adjudicated with no human touch; the core admin vendors' headline metric (Inside a Payer).
CAQH ProView: the shared credentialing profile a practitioner enters once and shares with the plans they designate; CAQH rebranded as DataSpring in 2026 (Credentialing, Enrollment & Provider Data).
Coinsurance: the member's percentage share of the allowed amount after the deductible (Payers & Plans).
Copay: a fixed amount the member pays per service type, often outside the deductible (Payers & Plans).
Credentialing: a payer's verification of a practitioner's licenses, training, history and sanctions from primary sources, with a committee decision and recredentialing on a cycle (Credentialing, Enrollment & Provider Data).
Deductible: what a member pays each benefit period before the plan pays, individual or family, embedded or aggregate (Payers & Plans).
ERISA: the federal law governing private employer benefit plans; it preempts state laws relating to self-funded plans while saving state insurance regulation of insurers (Payers & Plans).
Formulary: a plan's list of covered drugs, in tiers, with prior authorization, step therapy and quantity limits, versioned through the year (Pharmacy Benefits & PBMs).
LEIE (List of Excluded Individuals/Entities): the HHS OIG list of parties excluded from federal health care programs, whose items and services federal programs won't pay for (Credentialing, Enrollment & Provider Data).
MAC (Medicare Administrative Contractor): the regional contractor that processes Medicare Part A and B claims for a jurisdiction, or DME claims (Payers & Plans).
Medical loss ratio: the share of premium an insurer must spend on medical care (80% or 85% by market) or rebate (Payers & Plans).
Medicare Advantage: private plans paid per member by CMS that replace traditional Medicare Parts A and B for members who choose them; 55% of eligible beneficiaries in 2026 (Payers & Plans).
Network: the set of providers contracted to accept a payer's rates for a plan; participation is per practitioner, location and date (Payers & Plans).
Out-of-pocket maximum: the most a member pays in a benefit period for in-network covered care; $10,600 individual and $21,200 family for 2026 Marketplace plans (Payers & Plans).
Payer enrollment: loading a practitioner into a payer's system to be paid under a TIN at a location in a network from an effective date (Credentialing, Enrollment & Provider Data).
PBM (pharmacy benefit manager): the company that runs a plan's drug benefit: pharmacy network, formulary, rebates and real-time pharmacy claims (Pharmacy Benefits & PBMs).
PECOS: CMS's online Medicare enrollment system for providers and suppliers (Credentialing, Enrollment & Provider Data).
Provider Access API: the CMS-0057-F FHIR API giving in-network providers with a treatment relationship a member's claims, clinical and prior authorization data, required from January 1, 2027 (Inside a Payer).
Provider directory: a plan's public list of in-network providers, verified at least every 90 days and updated within 2 business days under the No Surprises Act (Credentialing, Enrollment & Provider Data).
Real-time benefit check: a query at prescribing time for a drug's coverage, prior authorization need and estimated cost-share, with alternatives, on NCPDP RTPB (Pharmacy Benefits & PBMs).
Rebate: a manufacturer's payment to a PBM for formulary position, arriving months after the claim (Pharmacy Benefits & PBMs).
Self-funded plan: an employer plan that pays claims from the employer's own money, administered by an insurer or TPA; 67% of covered workers in 2025 (Payers & Plans).
Spread pricing: a PBM charging the plan more for a claim than it pays the pharmacy and keeping the difference (Pharmacy Benefits & PBMs).
TiC (Transparency in Coverage) files: the machine-readable in-network rate and out-of-network allowed amount files plans must post publicly since July 1, 2022, revised by an October 2026 final rule (Inside a Payer).
TPA (third-party administrator): a company that processes claims for a self-funded plan without bearing the risk (Payers & Plans).
Utilization management: a payer's review of medical necessity before, during or after care: prior authorization, concurrent and retrospective review (Inside a Payer).