← Back to Platform Architecture
Payer Registry
Overview
The Payer Registry is a comprehensive database of 156 national and state-specific health insurance payers (commercial and Medicaid). Each payer record includes contact information, appeal process timelines, enforcement profiles with denial reason codes and overturn rates, and state/type classification for targeted precedent lookup and appeals routing.
Key characteristics:
- 156 payers across commercial (national carriers, regional blues) and Medicaid (state-managed plans)
- Appeal process detail — initial appeal deadline, standard and expedited review timelines, required addresses and phone numbers
- Enforcement profiles — denial reason code coverage, appeal overturn rates by payer (range: 25–80%), average days to decision
- State scope — national carriers plus state-specific Medicaid plans (CA, NY, PA, TX, FL initial focus)
- Public access — 1-hour TTL cache, no authentication required
Data Structure
Payer Record
{
"id": "cigna-commercial-national",
"name": "Cigna Health & Life Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@cigna.com",
"headquarters": {
"city": "Philadelphia",
"state": "PA",
"zip": "19192"
},
"appeal_process": {
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 72,
"addresses": [
{
"type": "initial_appeal",
"line1": "Cigna Appeals and Inquiries",
"line2": "P.O. Box 188061",
"city": "Chattanooga",
"state": "TN",
"zip": "37422"
},
{
"type": "external_review",
"line1": "Cigna External Review",
"line2": "27 Van Zant Street",
"city": "Norwalk",
"state": "CT",
"zip": "06855"
}
],
"phone_numbers": {
"appeal_line": "1-800-244-6224",
"fax": "1-423-265-3101"
},
"expedited_requirements": {
"required_for": ["emergency_care", "ongoing_treatment"],
"requires_physician_certification": true
}
},
"enforcement_profile": {
"denial_reason_codes": ["A0001", "A0003", "N0201", "N0204"],
"appeal_overturn_rate": 0.687,
"avg_days_to_decision": 18,
"precedent_count": 157
},
"updated_at": "2026-04-14T00:00:00Z"
}
Field Definitions
| Field | Type | Description |
id | string | Unique identifier (kebab-case: cigna-commercial-national, medicaid-ny-empire) |
name | string | Official payer legal name |
state | string \ | null | State code (e.g., NY, TX) for state-specific plans; null for national carriers |
type | enum | commercial, medicaid, medicare |
contact_email | string | Primary appeals contact email |
headquarters | object | city, state, zip |
appeal_process | object | See Appeal Process Detail section below |
enforcement_profile | object | See Enforcement Profile section below |
updated_at | ISO 8601 | Last data validation/refresh timestamp |
Appeal Process Detail
Each payer defines its own appeal timeline and routing. The appeal_process object standardizes this for precedent matching and appeals triage.
Key Fields
{
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 72,
"addresses": [
{
"type": "initial_appeal| reconsideration |
external_review",
"line1": "street address",
"line2": "suite/po box",
"city": "city",
"state": "state code",
"zip": "zip"
}
],
"phone_numbers": {
"appeal_line": "1-800-XXX-XXXX",
"fax": "1-YYY-ZZZ-ZZZZ"
},
"expedited_requirements": {
"required_for": ["emergency_care", "ongoing_treatment", "patient_disability"],
"requires_physician_certification": boolean,
"max_days_for_expedited": 72
}
}
Typical Timelines
Standard Appeal:
Day 0: Denial received
Day 30: Deadline to file initial appeal
Day 30–60: Standard review window (avg. 18–25 days for decision)
Day 61+: Appeal decision issued
Expedited Appeal:
Day 0: Request filed with physician cert
Day 3–5: Expedited review triggered
Day 3–5: Decision issued (72-hour target)
Notable payer variations:
Cigna: 30-day standard, 72-hour expedited, physician cert required for expedited
Aetna: 30-day standard, 48-hour expedited, allows nurse-to-nurse consult as alternative
Humana: 30-day standard, 72-hour expedited, requires "medically necessary" clinical justification
United: 30-day standard, 24-hour expedited for emergency care only
BlueCross variants: 30-day standard regional consistency; 48–72-hour expedited per state
Enforcement Profile
The enforcement profile captures what each payer denies (denial reason codes), how often they lose appeals (overturn rate), and how long decisions take.
Structure
{
"denial_reason_codes": ["A0001", "A0003", "N0201", "N0204"],
"appeal_overturn_rate": 0.687,
"avg_days_to_decision": 18,
"precedent_count": 157
}
Field Definitions
| Field | Type | Description |
denial_reason_codes | string[] | ASC codes or payer-specific codes this payer commonly uses (mapped to denial-reason-registry) |
appeal_overturn_rate | float (0–1) | Proportion of appeals overturned (reversed). Example: 0.687 = 68.7% overturn rate |
avg_days_to_decision | integer | Mean calendar days from appeal filed to decision issued |
precedent_count | integer | Number of precedent decisions in Stratum corpus for this payer |
Overturn Rates by Payer (Sample Data)
| Payer | Type | Denial Type | Overturn Rate | Precedent Count | Note |
| Cigna Commercial | Commercial | Behavioral health (all) | 68.7% | 157 | Highest overturn; loose auth criteria |
| Aetna | Commercial | Medical necessity | 62.4% | 142 | Clinical review disputes most common |
| Humana | Commercial | Prior auth missing | 45.2% | 89 | Stricter on administrative denials |
| UnitedHealth | Commercial | Frequency limits | 32.1% | 67 | Rigid frequency policies |
| BlueCross NY | Regional | All denial types | 55.3% | 103 | Moderate variance by code |
| Medicaid CA (DMHC) | Medicaid | All denial types | 41.8% | 76 | State-level variance; DMHC strict |
| Medicaid NY (DFS) | Medicaid | All denial types | 58.2% | 94 | State-level variance; DFS moderate |
| Medicaid PA | Medicaid | All denial types | 49.7% | 61 | Mid-range state variance |
| Medicare Advantage (aggregate) | Medicare | All denial types | 80.7% | 203 | Highest overturn; strong regulatory pressure |
Critical insight: Medicare Advantage (80.7%) and Cigna commercial (68.7%) show markedly higher overturn rates than UnitedHealth (32.1%) and Humana (45.2%). Do not blend MA and ACA post-service data in pitch materials — they operate under different appeal authority.
Query Examples
List All Payers
Endpoint: GET /api/v1/registries/payers
Request:
curl -X GET "https://platform.stratumcollective.co/api/v1/registries/payers" \
-H "Accept: application/json"
Response (200 OK):
{
"data": [
{
"id": "cigna-commercial-national",
"name": "Cigna Health & Life Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@cigna.com",
"appeal_process": { ... },
"enforcement_profile": { ... }
},
{
"id": "aetna-commercial-national",
"name": "Aetna Life Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@aetna.com",
"appeal_process": { ... },
"enforcement_profile": { ... }
},
...
],
"meta": {
"total": 156,
"timestamp": "2026-04-14T12:00:00Z",
"cache_ttl_seconds": 3600
}
}
Filter by State (Medicaid)
Endpoint: GET /api/v1/registries/payers?state=NY&type=medicaid
Request:
curl -X GET "https://platform.stratumcollective.co/api/v1/registries/payers?state=NY&type=medicaid" \
-H "Accept: application/json"
Response (200 OK):
{
"data": [
{
"id": "medicaid-ny-empire",
"name": "Empire Blue Cross Blue Shield (Medicaid)",
"state": "NY",
"type": "medicaid",
"contact_email": "appeals@empirebcbs.com",
"enforcement_profile": {
"appeal_overturn_rate": 0.562,
"avg_days_to_decision": 22,
"precedent_count": 94
}
},
{
"id": "medicaid-ny-aetna",
"name": "Aetna Better Health (NY Medicaid)",
"state": "NY",
"type": "medicaid",
"contact_email": "appeals@aetnabetterhealth.com",
"enforcement_profile": {
"appeal_overturn_rate": 0.487,
"avg_days_to_decision": 26,
"precedent_count": 67
}
}
],
"meta": {
"total": 2,
"timestamp": "2026-04-14T12:00:00Z",
"cache_ttl_seconds": 3600
}
}
Filter by Type (Commercial)
Endpoint: GET /api/v1/registries/payers?type=commercial
Request:
curl -X GET "https://platform.stratumcollective.co/api/v1/registries/payers?type=commercial" \
-H "Accept: application/json"
Response: Returns all 47 national and regional commercial carriers.
Search by Name
Endpoint: GET /api/v1/registries/payers/search?q=cigna
Request:
curl -X GET "https://platform.stratumcollective.co/api/v1/registries/payers/search?q=cigna" \
-H "Accept: application/json"
Response (200 OK):
{
"data": [
{
"id": "cigna-commercial-national",
"name": "Cigna Health & Life Insurance Company",
"state": null,
"type": "commercial",
"match_score": 1.0
},
{
"id": "cigna-regional-ca",
"name": "Cigna Healthcare of California",
"state": "CA",
"type": "commercial",
"match_score": 0.95
}
],
"meta": {
"timestamp": "2026-04-14T12:00:00Z"
}
}
Get Payer Detail
Endpoint: GET /api/v1/registries/payers/{id}
Request:
curl -X GET "https://platform.stratumcollective.co/api/v1/registries/payers/cigna-commercial-national" \
-H "Accept: application/json"
Response (200 OK):
{
"data": {
"id": "cigna-commercial-national",
"name": "Cigna Health & Life Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@cigna.com",
"headquarters": {
"city": "Philadelphia",
"state": "PA",
"zip": "19192"
},
"appeal_process": {
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 72,
"addresses": [
{
"type": "initial_appeal",
"line1": "Cigna Appeals and Inquiries",
"line2": "P.O. Box 188061",
"city": "Chattanooga",
"state": "TN",
"zip": "37422"
},
{
"type": "external_review",
"line1": "Cigna External Review",
"line2": "27 Van Zant Street",
"city": "Norwalk",
"state": "CT",
"zip": "06855"
}
],
"phone_numbers": {
"appeal_line": "1-800-244-6224",
"fax": "1-423-265-3101"
},
"expedited_requirements": {
"required_for": ["emergency_care", "ongoing_treatment"],
"requires_physician_certification": true
}
},
"enforcement_profile": {
"denial_reason_codes": ["A0001", "A0003", "N0201", "N0204"],
"appeal_overturn_rate": 0.687,
"avg_days_to_decision": 18,
"precedent_count": 157
},
"updated_at": "2026-04-14T00:00:00Z"
},
"meta": {
"timestamp": "2026-04-14T12:00:00Z",
"cache_ttl_seconds": 3600
}
}
Caching Strategy
TTL & Invalidation
Cache TTL: 1 hour (3600 seconds)
Cache key: payer_registry::list (full list), payer_registry::${id} (individual detail)
Invalidation triggers:
Manual data refresh (admin API)
Payer contact info or appeal timeline update
Precedent count change (e.g., new denial appeal in corpus)
Monthly validation audit
Client-Side Headers
Cache-Control: public, max-age=3600
ETag: "abc123def456"
Last-Modified: 2026-04-14T00:00:00Z
Backend Caching (Redis)
Payer registry is cached in Redis with hourly refresh from the source-of-truth database (PostgreSQL payers table).
Data Sources & Validation
Source of Truth
Primary source: PostgreSQL payers table (stratum-platform API)
Maintained manually with state insurance commissioner websites as reference
Validated quarterly against payer public appeal process documents
Precedent counts auto-updated from denial_precedents table (FK: payer_id)
Data Sources by Payer Type
#### National Commercial Carriers
Public sources: Payer appeal process documents (insurer.com/appeals)
Validation: Phone calls to appeals departments for timeline confirmation
Update frequency: Annual (timelines stable across years)
#### Regional BlueCross/BlueShield Plans
Public sources: State-specific BlueShield websites (each state has own plan)
Validation: State insurance commissioner filing documents
Update frequency: Biannual (regional variation common)
#### State Medicaid Plans
Public sources: State Medicaid agency websites (DMHC, DFS, DHS, HHSC, AHCA)
Validation: Medicaid managed care plan documents and state regulatory filings
Update frequency: Annual (state-level changes less frequent)
#### Medicare Advantage Plans
Public sources: CMS Medicare.gov database, plan-specific appeal documents
Validation: Cross-reference with CMS appeal timeline regulations
Update frequency: Annual (coordinated with CMS plan year)
Validation Rules
Contact Info Validation:
contact_email: Must be reachable; tested quarterly with dummy inquiry
Appeal address: Must match USPS postal database or payer's public filing
Phone numbers: Must be verified as active lines in appeal department
Appeal Timeline Validation:
Timelines must match or exceed regulatory minimums (PPACA, state law, CMS)
Discrepancies flagged for manual review with payer compliance document
Denial Reason Codes:
Must map to actual codes used by payer in denial letters
Validated against sample denials in precedent corpus
Gaps flagged (e.g., payer uses code not in registry)
Validation Audit Query
SELECT
p.id,
p.name,
p.type,
COUNT(dp.id) as precedent_count,
MAX(dp.created_at) as latest_precedent_date
FROM payers p
LEFT JOIN denial_precedents dp ON dp.payer_id = p.id
GROUP BY p.id, p.name, p.type
ORDER BY latest_precedent_date DESC;
Example Payers (Reference)
Cigna Commercial National
{
"id": "cigna-commercial-national",
"name": "Cigna Health & Life Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@cigna.com",
"headquarters": {
"city": "Philadelphia",
"state": "PA",
"zip": "19192"
},
"appeal_process": {
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 72,
"addresses": [
{
"type": "initial_appeal",
"line1": "Cigna Appeals and Inquiries",
"line2": "P.O. Box 188061",
"city": "Chattanooga",
"state": "TN",
"zip": "37422"
}
],
"phone_numbers": {
"appeal_line": "1-800-244-6224",
"fax": "1-423-265-3101"
},
"expedited_requirements": {
"required_for": ["emergency_care", "ongoing_treatment"],
"requires_physician_certification": true
}
},
"enforcement_profile": {
"denial_reason_codes": ["A0001", "A0003", "N0201", "N0204"],
"appeal_overturn_rate": 0.687,
"avg_days_to_decision": 18,
"precedent_count": 157
}
}
Key characteristics:
Highest overturn rate (68.7%) among commercial carriers
Loose medical necessity criteria; behavioral health appeal-friendly
Physician certification required for expedited
18-day average decision time
Aetna Commercial National
{
"id": "aetna-commercial-national",
"name": "Aetna Life Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@aetna.com",
"headquarters": {
"city": "Hartford",
"state": "CT",
"zip": "06156"
},
"appeal_process": {
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 48,
"addresses": [
{
"type": "initial_appeal",
"line1": "Aetna Appeals Department",
"line2": "P.O. Box 188005",
"city": "Hartford",
"state": "CT",
"zip": "06156"
}
],
"phone_numbers": {
"appeal_line": "1-800-752-7500",
"fax": "1-860-273-5254"
},
"expedited_requirements": {
"required_for": ["emergency_care"],
"requires_physician_certification": false
}
},
"enforcement_profile": {
"denial_reason_codes": ["A0001", "A0002", "N0201"],
"appeal_overturn_rate": 0.624,
"avg_days_to_decision": 21,
"precedent_count": 142
}
}
Key characteristics:
62.4% overturn rate; clinical review disputes most common
Faster expedited (48 hours vs. Cigna's 72)
No physician cert required; allows nurse-to-nurse consult
21-day average decision time
Humana Commercial National
{
"id": "humana-commercial-national",
"name": "Humana Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@humana.com",
"headquarters": {
"city": "Louisville",
"state": "KY",
"zip": "40202"
},
"appeal_process": {
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 72,
"addresses": [
{
"type": "initial_appeal",
"line1": "Humana Medical Review",
"line2": "500 W Main Street",
"city": "Louisville",
"state": "KY",
"zip": "40202"
}
],
"phone_numbers": {
"appeal_line": "1-800-444-4641",
"fax": "1-502-580-4434"
},
"expedited_requirements": {
"required_for": ["emergency_care", "patient_disability"],
"requires_physician_certification": true
}
},
"enforcement_profile": {
"denial_reason_codes": ["A0001", "N0204", "N0210"],
"appeal_overturn_rate": 0.452,
"avg_days_to_decision": 24,
"precedent_count": 89
}
}
Key characteristics:
45.2% overturn rate; stricter on administrative denials
Longer average decision time (24 days)
Requires "medically necessary" clinical justification for expedited
Smaller precedent corpus
UnitedHealth Commercial National
{
"id": "unitedhealthcare-commercial-national",
"name": "UnitedHealth Insurance Company",
"state": null,
"type": "commercial",
"contact_email": "appeals@united.com",
"headquarters": {
"city": "Minnetonka",
"state": "MN",
"zip": "55343"
},
"appeal_process": {
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 24,
"addresses": [
{
"type": "initial_appeal",
"line1": "UnitedHealthcare Appeals",
"line2": "P.O. Box 30623",
"city": "Salt Lake City",
"state": "UT",
"zip": "84130"
}
],
"phone_numbers": {
"appeal_line": "1-800-624-8822",
"fax": "1-801-587-2777"
},
"expedited_requirements": {
"required_for": ["emergency_care"],
"requires_physician_certification": true
}
},
"enforcement_profile": {
"denial_reason_codes": ["A0003", "N0210", "N0211"],
"appeal_overturn_rate": 0.321,
"avg_days_to_decision": 27,
"precedent_count": 67
}
}
Key characteristics:
Lowest overturn rate (32.1%) among commercial carriers
Rigid frequency policies; strict on behavioral health limits
Fastest expedited (24 hours) but only for emergency care
Longer average decision time (27 days)
BlueCross BlueShield NY (Regional)
{
"id": "bluecross-ny",
"name": "BlueCross BlueShield of New York",
"state": "NY",
"type": "commercial",
"contact_email": "appeals@bcbs.com",
"headquarters": {
"city": "New York",
"state": "NY",
"zip": "10007"
},
"appeal_process": {
"initial_appeal_deadline_days": 30,
"standard_review_days": 30,
"expedited_review_days": 48,
"addresses": [
{
"type": "initial_appeal",
"line1": "BCBS Appeals Unit",
"line2": "P.O. Box 1608",
"city": "New York",
"state": "NY",
"zip": "10008"
}
],
"phone_numbers": {
"appeal_line": "1-800-624-2000",
"fax": "1-212-848-8550"
},
"expedited_requirements": {
"required_for": ["emergency_care", "ongoing_treatment"],
"requires_physician_certification": false
}
},
"enforcement_profile": {
"denial_reason_codes": ["A0001", "A0003", "N0201", "N0204"],
"appeal_overturn_rate": 0.553,
"avg_days_to_decision": 20,
"precedent_count": 103
}
}
Key characteristics:
Regional moderate overturn (55.3%)
State-regulated (NY DFS oversight)
Consistent regional appeal process across NY
Medicare Advantage (Aggregate Profile)
{
"id": "medicare-advantage-aggregate",
"name": "Medicare Advantage Plans (Aggregate)",
"state": null,
"type": "medicare",
"contact_email": "n/a",
"headquarters": null,
"appeal_process": {
"initial_appeal_deadline_days": 60,
"standard_review_days": 30,
"expedited_review_days": 72,
"addresses": [],
"phone_numbers": {},
"expedited_requirements": {
"required_for": ["emergency_care", "ongoing_treatment"],
"requires_physician_certification": true
}
},
"enforcement_profile": {
"denial_reason_codes": ["ALL"],
"appeal_overturn_rate": 0.807,
"avg_days_to_decision": 14,
"precedent_count": 203
}
}
Key characteristics:
HIGHEST overturn rate (80.7%)
Federal Medicare appeal timeline (60 days vs. 30)
Strong regulatory pressure; CMS enforcement
Fastest average decision time (14 days)
Do NOT blend MA data with ACA post-service data in materials
See Also
Denial Reason Registry — Comprehensive ASC code mappings and payer-specific denial codes
State Behavioral Health Regulations — State-level appeal requirements and regulatory timelines
Insurance Plans Registry — Plan-specific details (formulary, network, coverage limits)
Precedent Decision Database — How precedent decisions are linked to payers and denial reasons