Which entity negotiates rates for provider services and processes claims?

The entity that negotiates rates for provider services and processes claims primarily refers to the health plan or payer. Health plans, which include insurance companies, are responsible for setting the reimbursement rates for healthcare providers. They negotiate contracts with providers to determine how much they will pay for various services, procedures, and treatments. This negotiation is crucial for establishing a network of providers that offer their services at predetermined rates.

Furthermore, health plans manage and process claims submitted by healthcare providers after services have been rendered. This process includes verifying coverage, determining eligibility, and ensuring that the claims meet the criteria set by the plan for reimbursement. Therefore, the negotiation of rates and the processing of claims are critical functions performed by health plans, making this the correct choice for the question.

Providers, while they provide care services, are not involved in negotiating rates with other providers but rather accept the terms set by payers. Patients are the recipients of healthcare services and do not negotiate rates directly. Insurance brokers serve as intermediaries who often facilitate the selection of health plans but do not negotiate provider rates or manage claims themselves.