Related Entities

In healthcare insurance, related entities play specialized roles, each contributing to how healthcare is administered and funded. Related entities may play a role in the routing of a claim.

Sohar Health returns an array of relatedEntities in the Get Verification API response with information about related entities. A related entity will have a payerName and an optional payerId. A memberId may be included if the related entity knows the member by a different ID to the main payer. The entityIdentifierCode is used to distinguish between different types of Coordination of Benefits payers.

The following types of related entity may be included in the API response.

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Utilization Management (UM)

Utilization management involves reviewing the necessity, appropriateness, and efficiency of healthcare services. UMs can be internal departments within an insurance company or external entities that assess whether services (like procedures, tests, or medications) are medically necessary before they are approved for coverage. This process may include prior authorization, concurrent reviews during hospitalization, or post-service reviews.

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Third-Party Administrators (TPAs)

TPAs manage administrative tasks for health plans, often for self-insured employers. They handle claims processing, enrollment, premium collection, and sometimes even customer service, without being the actual insurer. TPAs do not assume financial risk for claims but serve as intermediaries between members, providers, and insurance companies.

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Carve Outs

In a healthcare plan, certain services, like behavioral health, prescription drugs, or dental care, may be “carved out” from the standard insurance coverage and handled by a specialized provider. For example, a health plan might carve out behavioral health benefits to a separate organization, which then administers those benefits separately from the general medical benefits.

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Managed Care Organizations (MCOs)

MCOs manage and coordinate healthcare services to control costs and improve quality. Common examples include Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). They use techniques like provider networks, capitation payments, and quality assurance programs to oversee member care while managing financial risk.

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Coordination of Benefits (COB) Payers

COB refers to situations where a member has coverage from multiple insurance plans. A COB payer determines the order of payment when two or more insurers are responsible for covering the same claim. One insurer acts as the primary payer, while others may act as secondary or tertiary payers to cover the remaining balance.

COB payers are indicated in the entityIdentifierCode property of relatedEntities array by the following values:

PRP Primary Payer

SEP Secondary Payer

TTP Tertiary Payer