Payer
A payer is any organization that pays for healthcare services: commercial health insurers, Medicare and Medicaid, Medicare Advantage and Medicaid managed care plans, and employers that fund their own plans. In provider data, payers are the main users of provider directories.
Why do payers need provider data?
To build and maintain networks, publish directories, pay claims to the right entity, measure network adequacy, and guide members to care.
What rules apply to payers' directories?
It depends on the product. Group and individual plans fall under the No Surprises Act. Medicare Advantage plans follow CMS rules. Medicaid managed care plans follow 42 CFR 438.10 and state contracts.
Payer and provider
The provider delivers the care; the payer pays for it. Provider data is the shared record of who the providers are, where they practice and which payers they work with.