One platform runs your whole plan — so nothing falls through the cracks.
Adjudication, EDI, eligibility, member and employer portals, and compliance — engineered as one system instead of stitched together from legacy vendors. The result: claims paid right the first time, spend you can see in real time, and a single team accountable for all of it.
Illustrative product view of the SmartTPA claims dashboard.
Built to meet the strictest healthcare standards
- HIPAA Aligned2026 Security Rule
- Security-First ArchitectureSOC 2 in progress
- AES-256 EncryptionAt rest & in transit
- Immutable Audit Logs7-year retention
- Clearinghouse-Ready EDIClaims in, remittances out
Adjudication, EDI, portals, and compliance — one system, no integration project.
Adjudication Engine
A deterministic rules engine with automated coding validation layered on top. Applies plan benefits, fee schedules, accumulators, and coordination of benefits in under 2 seconds per claim — and finalizes 85–95% of clean claims that rules-only systems would pend for a person.
- Coding errors and upcoding caught before payment
- Automatic fee schedule lookups
- COB (coordination of benefits) detection
- Accumulator updates in real time
- Exception routing with reason codes
EDI Pipeline
Native electronic claims exchange, built in — claims flow in from your clearinghouse, remittances flow back out, and eligibility is answered in real time. No middleware, no bolted-on translator.
- Claims intake from any clearinghouse
- Electronic remittances back to providers
- Real-time eligibility responses
- Claim status answered electronically
- Direct payer connections available
Member & Employer Portals
Self-service that holds up in practice. Members check benefits, estimate costs, and ask questions. Employers see real-time analytics and anomaly alerts.
- Member cost estimator with real provider rates
- AI assistant for member benefits questions
- Digital ID cards and EOB history
- Employer dashboard with live metrics
- Broker co-branding and reporting
Compliance & Security
Aligned to the 2026 HIPAA Security Rule from day one. Every safeguard is mandatory now — our architecture was built for that world before it arrived.
- AES-256-GCM encryption at rest
- TLS 1.2+ in transit
- MFA enforced on all administrative access
- Immutable 7-year audit logs
- Field-level PHI encryption
From claim received to payment determined — in under two seconds.
Intake
Claims arrive electronically from your clearinghouse or by direct upload — parsed, validated, and enriched with member and provider context.
Validation
Automated checks screen coding, medical policy, and anomalies before a dollar moves. Clean claims continue automatically.
Adjudication
The rules engine applies plan benefits, fee schedules, deductibles, copays, and COB. 85–95% of clean claims finalize without human touch.
Remittance
Payment detail goes back to the provider electronically, the member's EOB posts to the portal, and the employer dashboard updates — all within seconds.
A TPA your employees might even thank you for.
Members get real answers, grounded in their actual plan data. Cost estimates before care. Deductible visibility in real time. An AI concierge chat that handles routine benefit questions so HR doesn't have to.
- Instant cost estimates for any procedure or provider
- Real-time deductible, OOP max, and accumulator tracking
- An AI assistant grounded in the member's actual plan — not a generic chatbot
- Digital ID cards and EOB history at their fingertips
How much will my MRI cost at Mercy Hospital?
Based on your plan and current deductible status, an MRI at Mercy Hospital is your in-network option. You've met about 57% of your deductible — your share at Mercy is roughly the remaining deductible plus your 20% coinsurance.
Any in-network imaging centers that cost less?
Yes — Northside Imaging is 4.2 miles away, meaningfully cheaper for the same scan, and has same-week availability.
Built to run — and built to keep protected data safe.
The platform runs on modern cloud infrastructure engineered for uptime and privacy, with every security setting reviewable and reproducible — no black boxes, no proprietary lock-in.
Multi-AZ cloud database with automated failover and encrypted backups
Encryption at rest and in transit on every record
An immutable, 7-year audit trail on every access to protected data
Security analysis in every release — regressions blocked before they ship
Infrastructure managed as code, so every control is reviewable and reproducible
Sub-2-second adjudication that scales with your group
See SmartTPA in action
See the platform in action.
Explore the interactive demo with sample data, or request a tailored proposal for your group.