End-to-end TPA services — automated where it counts, human where it matters.
Claims, pharmacy, reference-based pricing, COBRA, stop-loss, compliance — every piece of running a self-funded health plan, administered on one system with nothing hidden in the fees.
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
Nine services, one system, one accountable partner.
Where a service is best delivered by a specialist — pharmacy, reference-based pricing, clinical review — we contract independent partners, hold them to the same transparency standard, and take no hidden margin on any of it.
Claims Administration
Automated from intake to remittance.
Every claim, start to finish — accurately. A deterministic rules engine plus automated edit checks clear clean claims in under two seconds and catch the mispayments that quietly drain a plan, with a person on every real exception.
- Electronic claim intake via your clearinghouse
- 85–95% auto-adjudication on clean claims
- Fee schedule enforcement and COB
- Electronic remittances back to providers
- Appeals and denial management
Pharmacy Benefits
Pass-through pricing. No spread. No games.
Pharmacy is where hidden margin likes to hide. Your Rx benefit runs through an independent pass-through PBM partner: the plan pays what the pharmacy is paid, plus one disclosed fee. The PBM bills your plan directly, so pharmacy dollars never route through our books.
- Pass-through pricing — no spread on any prescription
- Rebate transparency: see what was earned and where it went
- Real-time claim adjudication at the pharmacy counter
- Medical and pharmacy deductibles tracked as one, kept in sync
- Low-cost sourcing, including cost-plus and warehouse pharmacies
Reference-Based Pricing
Rational prices, anchored to a public benchmark.
Network discounts obscure what care really costs. Reference-based pricing starts from what Medicare pays and prices every claim off that published benchmark instead — a defensible number, not a negotiated mystery. Members keep full choice of provider and get balance-bill support when a hospital pushes back.
- Claims priced from transparent, Medicare-anchored benchmarks
- No network restrictions — members see any provider
- Balance-bill defense and member advocacy included
- Provider engagement and dispute resolution handled for you
- Can meaningfully reduce stop-loss premiums at renewal
Utilization & Care Management
Clinical oversight, independent by design.
Prior authorization, concurrent review, and case management run through independent, URAC-accredited clinical partners. Appeals go to a separate independent review organization — the reviewer who hears an appeal is never the one who made the initial call.
- Prior authorization against evidence-based clinical criteria
- Concurrent review and discharge planning on inpatient stays
- Large-case management for complex and chronic conditions
- Independent external review (IRO) on clinical appeals
- Early identification of high-cost claimants from live claims data
COBRA Administration
Compliant continuation coverage, zero admin burden.
COBRA done right, off your plate. Notices, premium collection, and qualifying-event tracking run automatically and stay DOL-audit-ready — no spreadsheets, no missed deadlines, no compliance exposure.
- Initial notice and qualifying event letters
- Premium invoicing and collection
- Coverage termination tracking
- HIPAA-compliant member records
- DOL audit-ready reporting
Stop-Loss Coordination
Protect the plan from catastrophic claims.
Protection sized to your risk, and recoveries that get collected. Working with your broker and licensed stop-loss partners, we coordinate specific and aggregate coverage, then track triggers and file reimbursements automatically so nothing recoverable slips through.
- Specific and aggregate stop-loss
- Quote coordination across multiple carriers
- Laser negotiation support
- Automatic trigger tracking
- Reimbursement filing
Compliance & Reporting
HIPAA, ERISA, ACA — handled.
The filings and safeguards that keep plan fiduciaries out of trouble. Plan documents, Form 5500, ACA reporting, and an immutable audit trail — built to the 2026 HIPAA Security Rule from day one, not bolted on after a breach.
- Plan document drafting and updates
- Form 5500 preparation
- ACA reporting (1094/1095)
- HIPAA training and policies
- Immutable 7-year audit logs
Eligibility & Enrollment
Real-time eligibility, zero lag.
Coverage that's always current. Census, life-event changes, and dependent verification stay in sync automatically — and real-time eligibility means a provider knows exactly what's covered before the patient is in the chair.
- Census import and validation
- Life event and change tracking
- Dependent verification
- Real-time eligibility responses
- Member ID card generation
Employer Reporting
Real-time insight, not monthly PDFs.
Your plan's numbers the moment they happen — not 30 days later in a PDF. Live dashboards for spend, utilization, and high-cost claimants, with anomaly alerts the instant a pattern emerges. Drill into any claim; export anywhere.
- Real-time spend and utilization dashboards
- Demographic and claim pattern analytics
- High-cost claimant identification
- Benchmark comparisons
- Export to any BI tool
Every stakeholder gets what they need.
CFOs
- Lower administrative spend than legacy TPAs
- Catch the 5–10% of claims the industry mispays — before the money leaves
- Real-time visibility into plan spend
- Pharmacy with no spread pricing, and an RBP option when you want it
- Transparent fee structure with no surprises
HR Directors
- Fewer benefit questions on your desk — members self-serve first
- A member portal employees open on their own
- Faster claim resolution means fewer escalations
- Faster onboarding for new groups
From signed agreement to live claims — without the implementation slog.
Legacy TPAs spend 6–12 weeks hand-keying your plan into their system. Our platform reads your plan documents, drafts the configuration, and proves it with test claims before you go live.
- 1Kickoff
Agreement signed
You sign the services agreement. We provision your tenant.
- 2Upload
Plan document uploaded
Upload your SPD and census. The platform reads the plan and drafts the benefit configuration for you.
- 3Review
Configuration reviewed
You review and confirm the extracted configuration — corrections land in minutes, not days.
- 4Connect
EDI connections established
Clearinghouse or direct payer connections tested end-to-end, with real-time eligibility verified.
- 5Go live
Live claims processing
Your plan is live. Claims flowing. Dashboards lit up. Members onboarded.
See SmartTPA in action
Get a proposal tailored to your plan.
Tell us about your group size, current spend, and pain points. We’ll send a proposal within 2 business days.