# Payers Glossary

> 29 terms from the Health Tech book's Payers part, each defined in a line and linked to the chapter that explains it.

- **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](https://www.syntaqx.com/books/health-tech/payer-operations#accumulators)).
- **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](https://www.syntaqx.com/books/health-tech/pharmacy-benefits#copay-assistance-and-accumulators)).
- **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](https://www.syntaqx.com/books/health-tech/payer-operations#claims-adjudication)).
- **Auto-adjudication:** a claim adjudicated with no human touch; the core admin vendors' headline metric ([Inside a Payer](https://www.syntaqx.com/books/health-tech/payer-operations#claims-adjudication)).
- **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](https://www.syntaqx.com/books/health-tech/credentialing-and-enrollment#how-the-platforms-do-it)).
- **Coinsurance:** the member's percentage share of the allowed amount after the deductible ([Payers & Plans](https://www.syntaqx.com/books/health-tech/payers-and-plans#plan-design)).
- **Copay:** a fixed amount the member pays per service type, often outside the deductible ([Payers & Plans](https://www.syntaqx.com/books/health-tech/payers-and-plans#plan-design)).
- **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](https://www.syntaqx.com/books/health-tech/credentialing-and-enrollment#credentialing)).
- **Deductible:** what a member pays each benefit period before the plan pays, individual or family, embedded or aggregate ([Payers & Plans](https://www.syntaqx.com/books/health-tech/payers-and-plans#plan-design)).
- **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](https://www.syntaqx.com/books/health-tech/payers-and-plans#the-kinds-of-payer)).
- **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](https://www.syntaqx.com/books/health-tech/pharmacy-benefits#formularies-and-drug-utilization-management)).
- **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](https://www.syntaqx.com/books/health-tech/credentialing-and-enrollment#credentialing)).
- **MAC (Medicare Administrative Contractor):** the regional contractor that processes Medicare Part A and B claims for a jurisdiction, or DME claims ([Payers & Plans](https://www.syntaqx.com/books/health-tech/payers-and-plans#the-kinds-of-payer)).
- **Medical loss ratio:** the share of premium an insurer must spend on medical care (80% or 85% by market) or rebate ([Payers & Plans](https://www.syntaqx.com/books/health-tech/payers-and-plans#plan-design)).
- **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](https://www.syntaqx.com/books/health-tech/payers-and-plans#the-kinds-of-payer)).
- **Network:** the set of providers contracted to accept a payer's rates for a plan; participation is per practitioner, location and date ([Payers & Plans](https://www.syntaqx.com/books/health-tech/payers-and-plans#networks)).
- **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](https://www.syntaqx.com/books/health-tech/payers-and-plans#plan-design)).
- **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](https://www.syntaqx.com/books/health-tech/credentialing-and-enrollment#payer-enrollment)).
- **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](https://www.syntaqx.com/books/health-tech/pharmacy-benefits#the-parties-and-the-money)).
- **PECOS:** CMS's online Medicare enrollment system for providers and suppliers ([Credentialing, Enrollment & Provider Data](https://www.syntaqx.com/books/health-tech/credentialing-and-enrollment#medicare-enrollment)).
- **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](https://www.syntaqx.com/books/health-tech/payer-operations#payer-apis)).
- **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](https://www.syntaqx.com/books/health-tech/credentialing-and-enrollment#provider-directories)).
- **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](https://www.syntaqx.com/books/health-tech/pharmacy-benefits#real-time-benefit-checks)).
- **Rebate:** a manufacturer's payment to a PBM for formulary position, arriving months after the claim ([Pharmacy Benefits & PBMs](https://www.syntaqx.com/books/health-tech/pharmacy-benefits#the-parties-and-the-money)).
- **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](https://www.syntaqx.com/books/health-tech/payers-and-plans#the-kinds-of-payer)).
- **Spread pricing:** a PBM charging the plan more for a claim than it pays the pharmacy and keeping the difference ([Pharmacy Benefits & PBMs](https://www.syntaqx.com/books/health-tech/pharmacy-benefits#the-parties-and-the-money)).
- **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](https://www.syntaqx.com/books/health-tech/payer-operations#transparency-in-coverage-files)).
- **TPA (third-party administrator):** a company that processes claims for a self-funded plan without bearing the risk ([Payers & Plans](https://www.syntaqx.com/books/health-tech/payers-and-plans#the-kinds-of-payer)).
- **Utilization management:** a payer's review of medical necessity before, during or after care: prior authorization, concurrent and retrospective review ([Inside a Payer](https://www.syntaqx.com/books/health-tech/payer-operations#utilization-management)).

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