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Billing Terms Glossary

Commercial Payer Terms: Definitions for Therapists and Psychiatrists

These commercial payer terms are defined in plain English for therapists and psychiatrists. Commercial payer terms describe how private insurers and Blue plans are organized. BCBS is a federation of independent plans, so one plan's rules never apply to another by default.

In this section

36 terms defined
Written for psychotherapists and psychiatrists
Source organization linked on every entry

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Quiet behavioral health practice office with a desk and armchairs, the setting for our commercial payer terms glossary

Administrative Services Only (ASO)

General (all payers)

Also called: ASO; ASO contract

Definition: A contract in which an insurer or TPA administers a self-funded plan but does not carry the financial risk.
Why it matters: Explains why the same payer can have different rules for different employers.
Illustrative example: A payer's card says 'administered by' rather than 'underwritten by'.

Reference source U.S. Department of Labor, EBSA

Categories BCBS, UHC & Commercial Payer Terms

Aetna

Private payer

Also called: Aetna Behavioral Health

Definition: A national health insurer, part of CVS Health.
Why it matters: Has its own network, authorization, and appeal rules.
Illustrative example: A provider checks Aetna's provider portal.

Reference source Aetna

Categories BCBS, UHC & Commercial Payer Terms Aetna

Alpha Prefix

Private payer

Also called: member ID prefix; BCBS prefix; three-letter prefix

Definition: The first three characters of many Blue member IDs that identify the member's plan and are used to route claims.
Why it matters: Omitting or altering the prefix causes routing errors and rejections.
Illustrative example: A card shows a three-character prefix that must be entered.

Related terms BlueCard Program Member ID

Reference source Blue Cross Blue Shield Association

Categories BCBS, UHC & Commercial Payer TermsEligibility & Benefits Blue Cross Blue Shield

Anthem Blue Cross and Blue Shield

Private payer

Also called: Anthem BCBS; Anthem BCBS plans

Definition: A brand used by Elevance Health for its Blue plans in several states.
Why it matters: Anthem-branded plans share many processes but state plans have their own contracts and rules.
Illustrative example: A provider checks the Anthem plan for the member's state.

Verify: Anthem is not the same as every Blue plan; confirm by state.

Reference source Anthem

Categories BCBS, UHC & Commercial Payer Terms

Behavioral Health Carve-In

General (all payers)

Also called: carve-in; integrated behavioral health benefits

Definition: An arrangement in which the health plan manages behavioral health benefits itself instead of delegating them.
Why it matters: Simplifies claims routing but changes how authorizations and networks work.
Illustrative example: A payer moves behavioral health in-house and updates payer IDs.

Time-sensitive: carve-in and carve-out changes are frequent; verify current arrangements.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories BCBS, UHC & Commercial Payer TermsBehavioral Health Specific Terms

Behavioral Health Carve-Out

General (all payers)

Also called: BH carve-out; carved-out behavioral health; managed behavioral health organization; MBHO

Definition: An arrangement in which a plan delegates behavioral health benefits to a separate company, which handles authorizations, network, and claims.
Why it matters: The claim may go to a different payer or ID than the medical plan.
Illustrative example: A health plan card lists a separate behavioral health phone number and payer ID.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories BCBS, UHC & Commercial Payer TermsBehavioral Health Specific Terms

Blue Cross Blue Shield Association (BCBSA)

Private payer

Also called: BCBSA; Blue Cross Blue Shield federation

Definition: The national association of independent, locally operated Blue Cross and Blue Shield companies. BCBS is a federation of independent plans, not one company.
Why it matters: Rules, portals, and policies differ by licensee, so one plan's rules must never be generalized to another.
Illustrative example: A practice reads each state's Blue plan policy separately.

Reference source Blue Cross Blue Shield Association

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Blue Cross Blue Shield Licensee

Private payer

Also called: BCBS plan; Blue plan; regional BCBS licensee

Definition: An independent company licensed by the BCBSA to use the Blue names and marks in a defined service area.
Why it matters: Each licensee sets its own credentialing, fee schedules, authorization, and appeals.
Illustrative example: A therapist credentials with a state's Blue plan separately from a neighboring state's.

Verify: confirm licensee ownership and brand before generalizing.

Reference source Blue Cross Blue Shield Association

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Blue Shield of California

Private payer

Also called: BSC

Definition: An independent nonprofit Blue Shield plan serving California.
Why it matters: A separate plan with its own rules.
Illustrative example: A California provider uses Blue Shield's provider portal.

Related terms Blue Cross Blue Shield Licensee

Reference source Blue Shield of California

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

BlueCard Program

Private payer

Also called: BlueCard; out-of-area Blue claims

Definition: A BCBSA program that lets members of one Blue plan use providers of another Blue plan while claims are processed through the local plan.
Why it matters: Claims are filed with the local Blue plan, which forwards them to the member's home plan.
Illustrative example: A visiting member's claim is filed to the provider's local Blue plan.

Reference source Blue Cross Blue Shield Association

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Bright Health

General (all payers)

Also called: Bright HealthCare; NeueHealth

Definition: A company that offered insurance plans and later changed its business; current status must be verified.
Why it matters: Do not assume active plans without verification.
Illustrative example: A provider verifies whether a member's plan is still active.

Verify: current status not confirmed here; check the payer's official site.

Related terms Medicare Advantage Marketplace Plan

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories BCBS, UHC & Commercial Payer Terms

CareFirst

Private payer

Also called: CareFirst BlueCross BlueShield

Definition: A Blue licensee serving Maryland, the District of Columbia, and parts of Virginia.
Why it matters: A separate licensee with its own rules.
Illustrative example: A provider credentials with CareFirst separately.

Verify: confirm service area.

Related terms Blue Cross Blue Shield Licensee

Reference source CareFirst

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Carelon Behavioral Health

Private payer

Also called: Carelon; Beacon Health Options legacy

Definition: A behavioral health business within Elevance Health that manages behavioral health benefits for some plans.
Why it matters: A credentialing and claims contact for some Anthem behavioral health members.
Illustrative example: A provider is credentialed with the behavioral health administrator for a plan.

Verify: confirm current name and scope.

Reference source Elevance Health

Categories BCBS, UHC & Commercial Payer TermsBehavioral Health Specific Terms Anthem / Elevance

Centene

Private payer

Also called: Centene Corporation

Definition: A national managed care company focused on government programs, with subsidiaries that run Medicaid, Medicare, and marketplace plans.
Why it matters: Its subsidiaries have their own state plans and rules.
Illustrative example: A provider contracts with a Centene subsidiary plan in a state.

Reference source Centene

Categories BCBS, UHC & Commercial Payer Terms Centene / Molina / Wellcare / Magellan

Cigna Healthcare

Private payer

Also called: Cigna; The Cigna Group

Definition: A national health insurer and part of The Cigna Group.
Why it matters: Has its own network, authorization, and behavioral health arrangements.
Illustrative example: A provider checks Cigna's provider site.

Reference source Cigna Healthcare

Categories BCBS, UHC & Commercial Payer Terms Cigna / Evernorth

Elevance Health

Private payer

Also called: Elevance; formerly Anthem, Inc.

Definition: The health company, formerly Anthem, Inc., that operates Anthem-branded Blue plans and other health services businesses.
Why it matters: Explains the corporate name change from Anthem, Inc.
Illustrative example: A payer letter comes from Elevance Health.

Verify: confirm current corporate structure.

Reference source Elevance Health

Categories BCBS, UHC & Commercial Payer Terms Anthem / Elevance

Evernorth

Private payer

Also called: Evernorth Health Services

Definition: The health services business of The Cigna Group, which includes pharmacy and behavioral health services.
Why it matters: May administer behavioral health benefits for some plans.
Illustrative example: A provider is credentialed with a behavioral health administrator tied to Cigna.

Verify: confirm current arrangements.

Reference source Evernorth

Categories BCBS, UHC & Commercial Payer Terms Cigna / Evernorth

Florida Blue

Private payer

Also called: Blue Cross and Blue Shield of Florida

Definition: Florida's independent Blue licensee. It is not part of Anthem.
Why it matters: Florida Blue rules apply to Florida Blue members only.
Illustrative example: A Florida provider uses the Florida Blue provider site.

Related terms Blue Cross Blue Shield Licensee

Reference source Florida Blue

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

HCSC (Health Care Service Corporation)

Private payer

Also called: HCSC; Blue Cross and Blue Shield of Texas; BCBSTX

Definition: A Blue licensee company that operates Blue plans in several states, including Blue Cross and Blue Shield of Texas.
Why it matters: BCBS-TX is HCSC; its rules should not be assumed to apply to other licensees.
Illustrative example: A Texas therapist follows BCBS-TX provider manuals.

Verify: confirm the list of HCSC states.

Related terms Blue Cross Blue Shield Licensee

Reference source HCSC

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Highmark

Private payer

Also called: Highmark Blue Cross Blue Shield

Definition: A Blue licensee company operating Blue plans in several states.
Why it matters: Its rules apply to its own plans.
Illustrative example: A provider reads Highmark's manual for its area.

Verify: confirm service areas.

Related terms Blue Cross Blue Shield Licensee

Reference source Highmark

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Home Plan

Private payer

Also called: member's home Blue plan

Definition: Under BlueCard, the Blue plan that issued the member's coverage.
Why it matters: Determines benefits and cost sharing for out-of-area members.
Illustrative example: The home plan decides benefits for a traveling member.

Related terms Host Plan BlueCard Program

Reference source Blue Cross Blue Shield Association

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Horizon Blue Cross Blue Shield of New Jersey

Private payer

Also called: Horizon BCBSNJ

Definition: A Blue licensee serving New Jersey.
Why it matters: A separate licensee with its own rules.
Illustrative example: A New Jersey provider uses Horizon's provider portal.

Related terms Blue Cross Blue Shield Licensee

Reference source Horizon Blue Cross Blue Shield of New Jersey

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Host Plan

Private payer

Also called: local Blue plan

Definition: Under BlueCard, the Blue plan in the area where the provider is located, which processes the claim.
Why it matters: The provider deals with the host plan on claims.
Illustrative example: A provider bills the local Blue plan for an out-of-state member.

Related terms Home Plan BlueCard Program

Reference source Blue Cross Blue Shield Association

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Humana

Private payer

Also called: Humana Military

Definition: A national health insurer, strong in Medicare Advantage, and a TRICARE contractor in some regions.
Why it matters: Has its own network and rules.
Illustrative example: A provider checks Humana's provider portal.

Verify: contract roles change.

Related terms Medicare Advantage TRICARE

Reference source Humana

Categories BCBS, UHC & Commercial Payer Terms Humana

Independence Blue Cross

Private payer

Also called: IBX

Definition: A Blue licensee serving southeastern Pennsylvania.
Why it matters: A separate licensee with its own rules.
Illustrative example: A Pennsylvania provider uses IBX's provider site.

Verify: confirm service area.

Related terms Blue Cross Blue Shield Licensee

Reference source Independence Blue Cross

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Kaiser Permanente

Private payer

Also called: Kaiser; KP

Definition: An integrated health system and health plan, where members generally get care from Kaiser providers and contracted providers only when referred.
Why it matters: Community providers usually need a referral or contract.
Illustrative example: A Kaiser member needs authorization to see an outside therapist.

Reference source Kaiser Permanente

Categories BCBS, UHC & Commercial Payer Terms Kaiser Permanente

Magellan Health

Private payer

Also called: Magellan Healthcare; eMbrace

Definition: A behavioral health company now part of Centene that manages behavioral health benefits and some EAP services.
Why it matters: A provider may be credentialed with it for certain plans or EAPs.
Illustrative example: A provider joins Magellan's network for an EAP.

Verify: confirm current ownership and scope.

Reference source Magellan Health

Categories BCBS, UHC & Commercial Payer TermsBehavioral Health Specific Terms Centene / Molina / Wellcare / Magellan

Marketplace Plan

General (all payers)

Also called: ACA plan; exchange plan; individual plan

Definition: An individual or small-group health plan bought through a federal or state health insurance marketplace under the Affordable Care Act.
Why it matters: Marketplace plans have grace periods, metal tiers, and network limits that affect claims.
Illustrative example: A patient buys a silver plan on the exchange.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories BCBS, UHC & Commercial Payer TermsEligibility & Benefits

Molina Healthcare

Private payer

Also called: Molina

Definition: A national managed care company focused on government-sponsored programs, including Medicaid and Medicare plans.
Why it matters: Has state-specific plans and rules.
Illustrative example: A provider contracts with Molina in a state.

Reference source Molina Healthcare

Categories BCBS, UHC & Commercial Payer TermsMedicare & Medicaid Terms Centene / Molina / Wellcare / Magellan

Network Rental (PPO Repricing)

General (all payers)

Also called: network rental; PPO repricing; network access fee; repricing

Definition: A practice in which a third-party network's discounted rates are applied to claims from plans that rent that network.
Why it matters: Explains why a claim may be paid at a rate different from a direct contract, and why the contract and the remittance both need a close read.
Illustrative example: An ERA shows a repricing note for a rented network.

Verify: how rented networks apply varies by payer and contract; this entry defines the term and gives no response advice.

Related terms Contracted Rate Underpayment

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories BCBS, UHC & Commercial Payer TermsPayment & Reimbursement

Optum

Private payer

Also called: Optum Behavioral Health; OptumHealth

Definition: The health services business of UnitedHealth Group. Optum entities manage behavioral health benefits for many UnitedHealthcare plans and offer other services.
Why it matters: A therapist may be credentialed with Optum for UnitedHealthcare behavioral health.
Illustrative example: A claim goes to the payer ID listed for behavioral health on the card.

Verify: confirm current routing and naming.

Reference source Optum

Categories BCBS, UHC & Commercial Payer Terms UnitedHealthcare / Optum

Oscar Health

Private payer

Also called: Oscar

Definition: A health insurer focused on individual and small group marketplace plans.
Why it matters: Has its own network and rules.
Illustrative example: A provider checks Oscar's portal.

Related terms Medicare Advantage Marketplace Plan

Reference source Oscar Health

Categories BCBS, UHC & Commercial Payer Terms Commercial

Prominence Health Plan

Private payer

Also called: Prominence

Definition: A health plan based in Nevada, sometimes listed next to Blue plans. Whether it is a Blue licensee is not confirmed here, so treat it as a separate plan until you verify.
Why it matters: Assuming a plan is a Blue licensee can send you to the wrong rules and portals.
Illustrative example: A provider checks the plan's own provider site for credentialing and claims rules.

Verify: confirm whether it is a Blue licensee and its current operations at the plan's site.

Related terms Blue Cross Blue Shield Licensee

Reference source Prominence Health Plan

Categories BCBS, UHC & Commercial Payer Terms Blue Cross Blue Shield

Third-Party Administrator (TPA)

General (all payers)

Also called: TPA; claims administrator

Definition: A company that processes claims and manages benefits for a self-funded plan, often under a payer's brand.
Why it matters: The name on the card may not be the entity that owns the risk or sets the plan rules.
Illustrative example: A TPA processes claims and answers questions for an employer's self-funded plan.

Reference source U.S. Department of Labor, EBSA

Categories BCBS, UHC & Commercial Payer TermsEligibility & Benefits

UnitedHealthcare

Private payer

Also called: UHC; United Healthcare

Definition: A national health insurer that is part of UnitedHealth Group and offers commercial, Medicare Advantage, and Medicaid plans.
Why it matters: Has its own portals, policies, and behavioral health arrangements.
Illustrative example: A provider checks UnitedHealthcare's provider portal for authorization rules.

Related terms Optum

Reference source UnitedHealthcare

Categories BCBS, UHC & Commercial Payer Terms UnitedHealthcare / Optum

WellCare

Private payer

Also called: Wellcare

Definition: A Centene brand for Medicare Advantage, prescription drug, and some Medicaid plans.
Why it matters: Has its own portals and rules.
Illustrative example: A provider checks the plan's member ID and payer route.

Verify: confirm current branding.

Related terms Centene Medicare Advantage

Reference source Wellcare

Categories BCBS, UHC & Commercial Payer TermsMedicare & Medicaid Terms Centene / Molina / Wellcare / Magellan

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Commercial Payer Terms: Definitions for Therapists and Psychiatrists

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