Payers, Payer Groups, Lines of Business and Practices

Overview

Four registry entities describe who is contracting and for which population.

Entity	Definition	Scope
Payer	The entity that adjudicates and pays the claim	Global list plus your organization’s own payers
Payer Group	The parent organization a payer rolls up to	Your organization
Line of Business	The population or product line covered	Your organization
Practice	The billing entity that holds the contract	Your organization

The entities don’t reference each other directly. They are linked through canonical observations.

Payer

Payers come from two tiers:

Global payers are shared by every organization. The list is built from the Stedi payer network, NAIC-registered insurers, government programs and self-pay.
Organization payers exist only for your organization, such as a local TPA. If one has the same name as a global payer, yours takes precedence.

Column	Type	Description
`id`	uuid	Internal payer ID
`id_int64`	bigint	Stable integer ID, unique across all payers
`name`	string	Canonical payer name
`is_global`	boolean	`true` for global payers
`role`	string	Optional role of the payer in a contract

Global payers also carry matching attributes:

Column	Description
`payer_type`	How the payer is keyed: `stedi`, `naic`, `ein`, `government` or `self_pay`
`stedi_id`	Stedi’s permanent payer ID
`primary_payer_id`	Main EDI payer ID used on claims. Can change over time
`aliases`	Every EDI payer ID that routes to this payer
`dba`	Trade names, acronyms and former names
`naic_code`, `ein`, `eins`	Regulatory identifiers
`parent_payer_group_name`	Parent organization reported by the source network. Informational only
`programs`	Supported programs, e.g. `COMMERCIAL`, `MEDICARE`, `MEDICAID`
`coverage_types`	`medical`, `dental`, `vision`
`operating_states`	States the payer operates in
`active`	`false` once the payer leaves the source network. The row is kept

id_int64 ranges

Range	Assigned to
1,000 to 999,999	Global payers whose ID was adopted from a customer’s existing integer ID
1,000,000 and up	All other payers, global and organization, assigned in sequence

A small number of adopted IDs also sit at 9,000,000 and up. IDs are unique and never reused, but don’t rely on the range to tell global and organization payers apart; use is_global.

Payer Group

Column	Type	Description
`id`	uuid	Internal payer group ID
`name`	string	Group name, unique within your organization

Groups are seeded from the parent payers of the payers you contract with. A payer has no fixed group column. The payer-to-group link is recorded on each observation, so the same payer can roll up differently in different contexts.

Line of Business

Column	Type	Description
`id`	uuid	Internal LOB ID
`name`	string	LOB name
`bucket`	string	Optional roll-up category: `Commercial`, `Government` or `Other`. Can be empty

Organizations seeded with PriceMedic’s standard list get these values. Organizations whose lines of business come from their own data, for example during mastering, have their own list, and bucket may be empty:

Line of Business	Bucket
Commercial	Commercial
Marketplace	Commercial
Medicare	Government
Medicare Advantage	Government
Medicaid	Government
Government	Government
Workers’ Compensation	Other
Self-Pay	Other
Vision	Other
Secondary	Other
Other	Other

Plan type alone doesn’t set the LOB. A Medicare HMO is Medicare Advantage, not Medicare.

Practice

Column	Type	Description
`id`	uuid	Internal practice ID
`name`	string	Practice name
`ein`	string	Tax ID (TIN)
`group_npi`	string	Organizational (Type 2) NPI
`market`	string	Market or region
`type`	string	Practice type

name, ein and group_npi are each unique within your organization. Incoming data that would give two practices the same TIN or NPI is flagged for review, not merged.

How the IDs relate

Each record from your source data is resolved into a canonical observation: one row holding the IDs of the entities that appeared together. This is the only place the entities are linked.

Column	Points to	Required
`practice_id`	Practice `id`	Yes
`payer_id`	Payer `id`	Yes
`lob_id`	Line of Business `id`	Yes
`payer_group_id`	Payer Group `id`	No
`network_id`	Network `id`	No
`counterparty_id`	Counterparty `id`	No
`bound_fields`	Names of the dimensions that are set
`specificity`	Count of dimensions set. Higher is more specific

For example, one observation can say that Practice A contracts with Aetna, under the Aetna (CVS Group) payer group, for Medicare Advantage. Raw values are matched to entities in this order: a payer already seen for the same practice, exact name, a prior resolution, fuzzy match, AI-assisted match, then human review. Each match records the method used.

Data products

The entities are also published as tables in your organization’s registry database:

Table	Columns
`dim_payer_dp`	`id`, `id_int64`, `name`, `role`, `is_global`, `created_at`, `updated_at`, `org_slug`, `synced_at`
`dim_payer_group_dp`	`id`, `name`, `created_at`, `updated_at`, `org_slug`, `synced_at`
`dim_line_of_business_dp`	`id`, `name`, `bucket`, `created_at`, `updated_at`, `org_slug`, `synced_at`
`dim_practice_dp`	`id`, `name`, `ein`, `group_npi`, `market`, `type`, `created_at`, `updated_at`, `org_slug`, `synced_at`
`fact_canonical_observation_dp`	`id`, `practice_id`, `payer_group_id`, `payer_id`, `network_id`, `lob_id`, `counterparty_id`, `bound_fields`, `specificity`, `created_at`, `org_slug`, `synced_at`

The *_id columns in fact_canonical_observation_dp join to id in the matching dim_*_dp table. dim_payer_dp includes your payers and all global payers, so every payer_id joins. org_slug identifies your organization and synced_at is the last refresh time.

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Payers, Payer Groups, Lines of Business and Practices

Overview

Payer

id_int64 ranges

Payer Group

Line of Business

Practice

How the IDs relate

Data products

​Overview

​Payer

​id_int64 ranges

​Payer Group

​Line of Business

​Practice

​How the IDs relate

​Data products

Overview

Payer

id_int64 ranges

Payer Group

Line of Business

Practice

How the IDs relate

Data products