Top 75 Insurance Payers & Clearinghouses Every Medical Biller Should Know (2025 Directory)

If you want zero-guesswork billing in 2025, your edge is knowing which payers and clearinghouses move money fastest—and how to work each one with ruthless precision. Build your playbook with proven tactics from denials prevention, documentation integrity, CARC mastery, HIPAA compliance, and full-stack RCM execution. Level up your team with educators’ AMA strategies, targeted study tactics, and platform-smart software selection.

1) The 2025 map: what we mean by “payers” and “clearinghouses” (and why it prints money)

Payers span national commercial plans (UHC, Aetna, Cigna, Elevance/BCBS), Medicare, Medicaid MCOs, FEHB plans like GEHA, TRICARE/VA, regional health plans, workers’ comp administrators, and TPAs (UMR, Meritain, HealthSmart). Mastery here reduces touches, trims DNFB, and tightens your claims submission sequence. It also shrinks adjustments when your appeal letters cite the right CARC/RARC logic and your notes follow clinical documentation rules.

Clearinghouses are your traffic controllers—rejection feedback loops, ERA/EFT orchestration, payer-specific edits, eligibility, and attachments. The right hub pairs beautifully with your billing software stack and your downstream payment posting workflow. Tie that to rock-solid audit readiness and you’ll see first-pass yield lift quickly.

Multi-state teams should keep a credentialing/proficiency board that tracks payer-specific rules alongside coder licensure and state education requirements—start with state-by-state primers like California certification, Florida certification, Colorado certification, and Georgia certification, then scale across Illinois, Indiana, and Maryland as you hire.

If your scope includes telemedicine, IR, or bariatrics, cross-walk payer policies to our specialty coders’ maps for telehealth, interventional radiology, and bariatric surgery coding. For quality incentives, keep a MACRA cheat sheet from our QPP guide.

2) How to use this directory (selection criteria + quick wins)

We prioritized: (1) network scale and claim volume, (2) portal & EFT maturity, (3) ERA granularity, (4) denial/appeals transparency, (5) EDI reliability, and (6) billing-team feedback (from LinkedIn leadership Q&A, Reddit AMA lessons, and our RCM masterclass). Keep this article open next to your payer matrix, plug gaps with our software selection tips, and tighten your rejection ladder using the denials playbook.

Quick wins you can implement today

• Enroll or re-enroll for ERA/EFT wherever available and hard-stop paper EOBs—then revamp rules in your payment posting queue.

• Add a “Top 20 rejections” kanban linked to payer edits; match root-cause rules to our CARC code explainer.

• Create specialty-specific checklists for telehealth modifiers, trauma coding, and HIPAA-secure workflows.

• Audit high-value visits with our clinical documentation rules to preempt post-pay recoupments.

Top 75 Insurance Payers & Clearinghouses (2025 Directory)

#	Type	Organization	Primary Portal / EDI	What To Know (ERA/EFT • Edits • Tips)
1	Payer	Medicare (FFS)	MAC portals; HETS; EDI via multiple hubs	Strict NCD/LCD & MUEs; enroll EFT/ERA; watch sequestration & modifier rules.
2	Payer	Medicaid (State Programs)	State portals; MCO carve-outs	Eligibility nuances; prior auth intensity; confirm MCO vs FFS routing.
3	Payer	UnitedHealthcare	UHC Provider Portal; Optum EDI	Nav for PA & appeals; verify place-of-service & telehealth modifiers.
4	Payer	Aetna (CVS Health)	Availity; Aetna portal	ERA granularity strong; manage bundling logic on surgical episodes.
5	Payer	Cigna Healthcare	Availity; Cigna portal	Check site-of-service policies; appeals windows tight.
6	Payer	Elevance Health (Anthem BCBS)	Availity	BCBS plan-by-plan differences; use payer-specific payer IDs.
7	Payer	Humana	Availity; Humana portal	Strong MA footprint; risk-adjustment coding affects audits.
8	Payer	Kaiser Permanente	Kaiser portals	Closed network processes; confirm referral/authorization pathways.
9	Payer	Centene / Ambetter / WellCare	Availity; payer portals	State-specific edits; MCO PA is pivotal for first-pass success.
10	Payer	Molina Healthcare	Availity; Molina portal	Check Medicaid-to-MA crossover; tight auth on imaging.
11	Payer	HCSC (BCBS IL/TX/OK/NM/MT)	Availity	Plan differences across states; payer ID precision required.
12	Payer	Florida Blue (BCBS FL)	Availity	Local LCDs for specialties; manage inpatient auth transitions.
13	Payer	Blue Shield of California	Availity; BSC portal	Distinct from Anthem CA; verify payer IDs carefully.
14	Payer	Regence / Asuris	Availity	Northwest rules; verify OON benefits for telehealth.
15	Payer	Premera Blue Cross	Availity	Alaska/Washington specifics; mental health carve-outs.
16	Payer	Highmark	Availity	Pennsylvania/WV footprint; HMO vs PPO edits differ.
17	Payer	Independence Blue Cross	Availity	Philadelphia region; monitor experimental procedure policies.
18	Payer	EmblemHealth / GHI	Emblem portal	New York authorizations; behavioral health vendor carve-outs.
19	Payer	Fidelis Care (NY)	Availity; Fidelis portal	Medicaid/Marketplace rules; attach notes for complex cases.
20	Payer	Oscar Health	Oscar portal	Younger network; verify referrals; telehealth benefits vary.
21	Payer	Tufts / Point32Health	Tufts portal	MA & commercial lines; strict PA for imaging/surgeries.
22	Payer	Harvard Pilgrim / Point32Health	HPI portal	New England focus; check telehealth parity.
23	Payer	UPMC Health Plan	UPMC portal	PA network alignment crucial; inpatient authorization nuances.
24	Payer	Priority Health (MI)	Priority portal	MA & commercial; verify tiering for specialty services.
25	Payer	Geisinger Health Plan	GHP portal	Regional policies; inpatient-to-observation edits.
26	Payer	TRICARE (Humana/Health Net/Express Scripts)	Regional portals	Region-specific rules; referral/PA rigor high.
27	Payer	VA Community Care Network	Optum/Anthem admins	Authorization routing critical; attach records promptly.
28	Payer	Railroad Medicare	Palmetto GBA	Specialized edits; distinct from Part B locality rules.
29	Payer	GEHA (FEHB)	GEHA portal	Federal employee benefit nuances; check OON reimbursement.
30	Payer	Meritain Health (Aetna TPA)	Meritain portal	Self-funded plan rules vary by employer; verify benefits.
31	Payer	UMR (UHC TPA)	UMR portal	Employer-specific carve-outs; check prior auth matrix.
32	Payer	Allied Benefit Systems	Allied portal	Self-funded variability; appeal with plan document cites.
33	Payer	HealthSmart	HealthSmart portal	Network vs repricing arrangements; verify payer ID.
34	Payer	WebTPA	WebTPA portal	Self-funded; ensure coordination with stop-loss rules.
35	Payer	PEHP (Utah)	PEHP portal	State plan requirements; check referral rules.
36	Payer	MedCost	MedCost portal	Regional network; verify repricing entities.
37	Payer	Workers’ Comp—State Funds	State portals	Attach clinical notes & work status; slower adjudication.
38	Payer	Sedgwick (Workers’ Comp)	Sedgwick portal	TPA for many employers; documentation completeness key.
39	Payer	CorVel (Workers’ Comp)	CorVel portal	Bill review rigor; CPT/fee schedule precision required.
40	Clearinghouse	Availity	Portal + EDI	Dominant for BCBS/Aetna/Cigna; rich eligibility & auth tools.
41	Clearinghouse	Waystar	EDI + analytics	Robust claim edits, ERA automation, patient estimation.
42	Clearinghouse	Change Healthcare (Optum)	EDI Network	Massive connectivity; check latest payer IDs post-mergers.
43	Clearinghouse	Cognizant TriZetto	EDI + payer rules	Powerful edit libraries; watch companion guides per payer.
44	Clearinghouse	The SSI Group	Claims & attachments	Hospital-friendly tools; UB-04 optimization.
45	Clearinghouse	Experian Health	EDI + eligibility	Strong coverage discovery & propensity models.
46	Clearinghouse	Office Ally	EDI + Payer Portal	Popular with small practices; broad basic connectivity.
47	Clearinghouse	Claim.MD	EDI portal	Quick enrollment; transparent rejections; good for startups.
48	Clearinghouse	Smart Data Solutions	EDI + mailroom	Attachments & paper-to-digital acceleration.
49	Clearinghouse	Optum iEDI	EDI	Deep payer ties; ensure companion guides are current.
50	Clearinghouse	Relay Exchange	EDI	Large legacy network; confirm payer mapping updates.
51	Clearinghouse	TruBridge	EDI + rural focus	Critical access hospital strengths; UB clean-up.
52	Clearinghouse	eSolutions (now Waystar)	EDI	Medicare crossover expertise; hospice/HHA tools.
53	Clearinghouse	Quadax	EDI + AR	Lab/diagnostic strength; denial analytics.
54	Clearinghouse	NaviNet	Portal	Payer collaboration; eligibility & messaging.
55	Clearinghouse	GHX eCommerce (EDI)	EDI / remits	Some payer pipes; verify payer list for claims.
56	Clearinghouse	PracticeSuite Clearinghouse	Embedded EDI	Aligned to PMS; confirm payer enrollments.
57	Clearinghouse	Plexis Healthcare Systems	EDI	Payer/TPA platform; niche connectivity.
58	Clearinghouse	Practice Insight (eMDs)	EDI	Independent practice fit; watch payer IDs.
59	Clearinghouse	Jopari (Attachments/WC)	eBill + attachments	Workers’ comp strengths; state eBill compliance.
60	Clearinghouse	Trizetto ERAs (Cognizant)	ERA/EFT	ERA normalization; auto-posting configs.
61	Payer	Health Net	Health Net portal	CA focus; check CMG participation & auth.
62	Payer	CDPHP	CDPHP portal	NY plan; keep PA matrix handy.
63	Payer	Emory Healthcare Plan	Portal	Employer plan rules vary; confirm benefits.
64	Payer	Scott & White Health Plan	SWHP portal	Central Texas; referrals matter.
65	Payer	Blue Cross NC	Availity	Local policies; check imaging auth vendor.
66	Payer	Blue Cross MA	Availity/NaviNet	Parity on telehealth; reimbursement schedules vary.
67	Payer	Prevea360 / Quartz	Quartz portal	WI/IA footprint; prior auth vigilance.
68	Payer	Banner|Aetna	Availity	Arizona network; double-check payer ID.
69	Payer	Intermountain Health Plan (SelectHealth)	SelectHealth portal	Mountain West rules; tiering/PA strict.
70	Payer	Priority Partners (MD Medicaid MCO)	Portal	MCO rules; attach medical necessity quickly.
71	Payer	AmeriHealth Caritas	Portal	Several state MCOs; frequent policy bulletins.
72	Payer	Presbyterian Health Plan (NM)	PHP portal	Regional edits; verify networks for specialties.
73	Payer	SummaCare	Summa portal	Ohio regional; check radiology auth vendor.
74	Payer	HAP (MI)	HAP portal	Detroit metro; MA policies prominent.
75	Payer	Wellmark BCBS (IA/SD)	Availity	Regional fee schedules; check telehealth parity rules.

3) Playbook: crushing first-pass yield with payer-specific habits

Start by standardizing enrollment—ERA/EFT + portal access—for your top-20 volume payers. Assign an owner for each payer, maintain a “what changed” log, and update edits every Friday. Anchor your routines to the claims submission process and map your most common CARC denial reasons to concrete fixes. Then, pressure-test documentation with our CDI checklist before you hit “submit.”

Fast wins across big payers

• UHC/UMR: Verify site-of-service and add PA proofs to avoid medical necessity denials; use Optum eligibility and build automation with your software stack.

• Aetna/Meritain: Watch surgical bundling; attach op notes proactively and monitor short appeal windows using our denial management guide.

• Cigna: Scrub POS/telehealth logic; embed modifier cheat sheets from the telemedicine coding playbook.

• BCBS plans (Elevance/HCSC/Wellmark/Regence): Payer ID precision is everything. Version your edits at the plan level and document variances in a shared workbook; refresh training with our educators AMA.

• Medicare/Railroad: Track NCD/LCD updates; run pre-bill audits guided by coding audits best practices; route complex cases (IR/trauma) via our IR and trauma maps.

Clearinghouse tactics that pay off

• Turn on claim attachment workflows (esp. imaging/surgical) and enforce zero manual faxing; this alone accelerates payment posting—then use our payment posting guide to auto-post remits cleanly.

• Normalize ERA reason codes and build a mini “reasons → actions” library mapped to CARC logic.

• For denials focused practices (ED/ASC/orthopedics), implement our denials prevention blueprint and add payer-specific pre-auth checklists.

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4) Denials, AR, and audit defense—make rejections a rounding error

Pre-submission controls are everything: demographics verification, eligibility (with COB), PA proofs, medical necessity, LCD policy checks, and specialty modifiers. Build your guardrails from our RCM master guide and hard-code them into your software rules engine. Align your team’s weekly cadence:

• Day 1: Rejections sweep → fix within 24 hours using CARC mapping.

• Day 2–3: Denials work-down → use templates from the denials guide.

• Day 4: Audit look-backs → anchor to coding audit protocols.

• Day 5: Education refresh → target gaps with CDI fundamentals and exam-passing tactics.

For telehealth/ASC/IR high-variance edits, pre-route tricky encounters to senior coders and cross-check our telemedicine rules, ASC denial control, and bariatric episode coding. To reduce rework, improve intake scripting with insights from our LinkedIn billing leader Q&A.

Which payer or clearinghouse slows your reimbursements most?

UnitedHealthcare / UMR Aetna / Meritain Cigna BCBS plan (Elevance/HCSC/Wellmark/Other) Medicare / Railroad Medicaid / MCO Workers’ Comp / TPA Clearinghouse issues (rejections/attachments) Submit Your feedback guides our next deep-dive. Keep our [denials guide](https://ambci.org/medical-billing-and-coding-certification-blog/comprehensive-guide-to-denials-prevention-and-management) handy.

5) Remote teams, multistate payers, and career leverage

Modern billing teams are hybrid, remote, and national. That means different payer rules, varied Medicaid MCOs, and unique credentialing steps. Use state certification pages to build onboarding tracks for new hires: Alabama, Arizona, Colorado, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, and Mississippi. Create a “payers by state” matrix and link your top five per state to internal SOPs.

To accelerate careers and recruiting, study our guides to remote roles (use as placeholder), real-world wisdom from Reddit AMAs, and leadership insights from the LinkedIn billing landscape Q&A. For coders targeting high-acuity settings, sharpen with our complex trauma coding and IR billing primers, then keep compliance tight with HIPAA essentials.

Finally, stitch your tech stack to your payer network. If your PMS/EMR bundles billing features, compare them using our software solutions guide and build payer-specific worklists. Add ERA auto-post rules and reconciliation tasks anchored to the payment posting roadmap and you’ll feel AR days sliding down fast.

6) FAQs (detailed and practical)

• Q1) How should I prioritize payer enrollments (ERA/EFT and portals) if I’m short on time?

  Start with your top-20 payers by claim volume and high-variance denial sources (usually MA/MCO lines). For each, enroll ERA/EFT, confirm payer IDs in your clearinghouse, and update your SOPs. Use our claims submission guide to re-map workflows, then route all rejections to a same-day queue guided by the denials blueprint.

• Q2) What’s the fastest way to cut rejections with clearinghouses?

  Turn on claim-level attachments, normalize ERA reason codes, and enable payer-specific edit packs. Build a mini library mapping CARC/RARC to fixes using our CARC explainer. Then integrate auto-posting and reconciliation using the payment posting playbook.

• Q3) My denials are mostly “medical necessity” and “no auth.” What should I change first?

  Implement a PA proof checklist at scheduling and a medical necessity gate in coding. For high-risk lines (imaging, surgeries, telehealth), cross-reference payer policies and plug our telemedicine coding rules and CDI guidelines. Audit weekly using the coding audit framework.

• Q4) We’re expanding to new states. What changes most for billing?

  Medicaid and local BCBS policies. Build state folders with top payers, MCOs, payer IDs, auth vendors, and fee schedules. Use our state certification pages—start with California, Florida, Illinois, and Maryland—to create onboarding checklists and speed credentialing.

• Q5) Which tools matter most for a lean, remote billing shop?

  A reliable clearinghouse, a PMS/EMR with solid claim edits, eligibility + auth automation, and tight payment posting. Start with our software guide, then operationalize day-to-day using the RCM master guide and denial prevention playbook.

• Q6) How do I keep auditors happy without slowing production?

  Bake quality into the workflow: a light-touch pre-bill CDI check, weekly audit samples by payer/specialty, and quarterly refreshers based on our audit guide and documentation essentials. Use payer-specific appeal templates and track overturn rates by reason to guide training.