Question 1

What is SmartTPA?

Accepted Answer

SmartTPA is a modern Third Party Administrator for self-funded employer health plans. It handles claims intake, medical coding validation, adjudication, eligibility verification, and EDI transactions in a single HIPAA-aligned platform — and pairs that with transparent plan economics: pass-through pharmacy benefits, an optional reference-based pricing design, and independent utilization and care management.

Question 2

Who is SmartTPA for?

Accepted Answer

SmartTPA is for self-funded employers who want their health plan administered accurately, transparently, and without the legacy-TPA headaches — and for the brokers who place and renew those groups. It's built just as deliberately for the people on the other end: members who get straight answers about their benefits, and providers who get paid quickly with far less back-and-forth.

Question 3

How does the free claims analysis work?

Accepted Answer

You send us a claims extract — a standard file your current TPA, carrier, or clearinghouse already produces. We run it through our pricing engine and pass-through pharmacy model and return a line-by-line report showing what the same claims would have cost with us, medical and pharmacy itemized. It's free and carries no obligation — you keep the report either way.

Question 4

Do I need to migrate my data to start?

Accepted Answer

No. The claims analysis needs only a one-time claims file. Nothing connects to your systems, no integration work is required, and your current plan continues running untouched.

Question 5

What does “auto-adjudication” mean?

Accepted Answer

Auto-adjudication means the claims engine processes a claim from intake to payment determination without human intervention. Our rules engine applies plan benefits, fee schedules, deductibles, copays, coinsurance, and OOP maximums automatically. Only claims that trigger exception rules are pended for manual review.

Question 6

What's your auto-adjudication rate?

Accepted Answer

The platform is designed to auto-adjudicate 85-95% of clean claims, depending on plan complexity and claim mix. The remainder are pended for human review with pre-populated recommendations. The high end of that range comes from layering automated edit checks (coding validation, modifier checks, NCCI/MUE screens) on top of the deterministic rules engine — checks that rules-only legacy systems skip or apply inconsistently.

Question 7

How automated is claims processing — and who decides denials?

Accepted Answer

Routine processing is automated end-to-end: the platform verifies eligibility, applies the plan document, prices the claim, and updates deductibles and out-of-pocket accumulators. That automation is why administration costs less and reporting is real-time. Administrative determinations — eligibility, plan coverage terms, duplicates, timely filing — follow the plan document exactly, and exceptions route to people. Medical-necessity decisions are never automated: prior authorization and clinical review run through an independent, URAC-accredited utilization management partner, and appeals are heard by reviewers who were not involved in the original decision, with independent external review where applicable. Every denial states its reason in plain language and explains how to appeal.

Question 8

How fast is adjudication?

Accepted Answer

Average adjudication time is under 2 seconds per claim. This includes eligibility verification, fee schedule lookup, benefit application, accumulator updates, and result generation.

Question 9

What denial codes do you support?

Accepted Answer

We support the full CARC (Claim Adjustment Reason Code) and RARC (Remittance Advice Remark Code) code sets as required by X12 835 transactions. Common denial reasons include timely filing (CARC-29), non-covered services (CARC-96), and duplicate claims (CARC-18).

Question 10

How does SmartTPA handle pharmacy benefits?

Accepted Answer

Your pharmacy benefit runs through an independent pass-through PBM partner. Pass-through means the plan pays what the pharmacy is paid, plus one disclosed administrative fee — no spread pricing, no hidden markup on any prescription. Rebates are reported transparently, the PBM bills your plan directly, and medical and pharmacy deductibles stay in sync so members are never overcharged at the counter.

Question 11

What is a pass-through PBM?

Accepted Answer

A pass-through PBM charges the plan exactly what it reimburses the pharmacy, earning its revenue from a disclosed per-member or per-claim fee. Traditional PBMs profit from 'spread' — billing the plan more than they pay the pharmacy and keeping the difference — and from retaining rebates. The pass-through model removes both incentives, which is why we require it of our pharmacy partner.

Question 12

What is reference-based pricing (RBP)?

Accepted Answer

Reference-based pricing pays claims from a published benchmark — typically a multiple of what Medicare pays for the same service — instead of a negotiated network discount off an inflated billed charge. There is no network: members can see any provider. SmartTPA offers RBP as a plan design option, with claim repricing, provider engagement, and member balance-bill defense handled through an established RBP partner.

Question 13

Do you offer PPO network plans, or only reference-based pricing?

Accepted Answer

Both. Reference-based pricing is one plan design option, not a requirement. Employers who prefer a traditional design can run a PPO network plan on the same platform — the adjudication engine prices from network contract rates automatically, the same way it applies any fee schedule. Your broker can quote either design (or compare both) in a proposal.

Question 14

What happens if a member gets a balance bill under RBP?

Accepted Answer

Balance-bill support is built into the plan design, not sold separately. If a provider bills a member for the difference between its charge and the plan's reference-based payment, the member hands the bill to us: advocates engage the provider, negotiate or dispute the balance, and — where needed — provide legal defense. Members are supported through the entire process and coached never to just pay the bill.

Question 15

Do you offer utilization management and case management?

Accepted Answer

Yes. Prior authorization, concurrent review, and large-case management are available through independent, URAC-accredited clinical partners. External appeal reviews go to a separate independent review organization (IRO) — never the organization that made the initial determination. The platform also flags high-cost claimants early from live claims data, so case management starts before costs run away.

Question 16

How does SmartTPA lower total plan spend?

Accepted Answer

Four levers, in order of reliability: pay claims correctly the first time (coding validation and edit checks catch the 5–10% of claims the industry mispays); remove pharmacy spread with a pass-through PBM; offer reference-based pricing so claims start from a rational benchmark instead of an inflated charge; and align stop-loss coverage with live claims data so recoveries get collected. None of it depends on members using less care.

Question 17

What EDI transactions do you support?

Accepted Answer

We support X12 837P (professional claims), 837I (institutional claims), 835 (remittance/payment), 270/271 (eligibility inquiry/response), and 276/277 (claim status inquiry/response). All transactions are HIPAA-aligned and clearinghouse-compatible.

Question 18

Do I need a clearinghouse?

Accepted Answer

SmartTPA works with your existing clearinghouse or can connect directly to payers. Our EDI pipeline handles parsing, validation, and generation natively — no middleware required.

Question 19

Can I integrate with my existing systems?

Accepted Answer

Yes. SmartTPA provides a full REST API for integration with your existing practice management systems, billing platforms, and reporting tools.

Question 20

Is SmartTPA HIPAA aligned?

Accepted Answer

Yes. SmartTPA is built for the 2026 HIPAA Security Rule, which eliminates addressable safeguards — every control is now mandatory. We implement AES-256 encryption at rest, TLS 1.2+ in transit, multi-factor authentication, immutable audit logs, and 7-year retention. We also support field-level encryption for PHI.

Question 21

Where is SmartTPA hosted?

Accepted Answer

SmartTPA runs as a fully managed service on AWS, with multi-AZ redundancy, automated failover, and KMS-managed encryption keys. We operate the infrastructure ourselves — that's how we keep every HIPAA control verifiable, auditable, and consistent for every plan we administer. Your data is exportable in standard formats at any time.

Question 22

What about SOC 2?

Accepted Answer

SOC 2 Type II is in progress. Our infrastructure already runs with encryption at rest and in transit, immutable audit logging, and least-privilege access controls — we share detailed security documentation and sign BAAs during evaluation.

Question 23

How long are audit logs retained?

Accepted Answer

All audit logs are retained for 7 years in immutable, append-only storage. Every access, modification, and system event is logged with timestamps, user IDs, and IP addresses.

Question 24

How do you charge for SmartTPA?

Accepted Answer

We disclose pricing in direct sales conversations and signed agreements. Reach out for a tailored proposal — every employer's plan, group size, and claim volume looks different, and we structure pricing to match. The free claims analysis is zero-cost, zero-obligation.

Question 25

Are there hidden fees?

Accepted Answer

No. The fee structure is transparent — no per-claim surcharges, no spread pricing, no claim-editing markups, no out-of-network repricing markup. CAA-compliant compensation disclosure on every engagement.

Question 26

What if I want to cancel?

Accepted Answer

The free claims analysis carries zero cost and zero obligation — you keep the report either way. Going live is a committed engagement, and the exact term and notice period are spelled out in your services agreement. Whenever the relationship ends, we help you export your data in standard formats, so your data is never locked in.

Answers to the questions we hear most.

Getting Started

Claims & Adjudication

Pharmacy & Cost Control

EDI & Integrations

Compliance & Security

Pricing & Engagement

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