Question 1

What is SmartTPA?

Accepted Answer

SmartTPA is a third-party administrator for self-funded employer health plans. It handles claims intake, coding validation, adjudication, eligibility, and EDI in a single HIPAA-aligned platform, and pairs that with plan economics that carry no hidden margin: pass-through pharmacy benefits, an optional reference-based pricing design, and independent utilization and care management.

Question 2

Who is SmartTPA for?

Accepted Answer

Self-funded employers who fund their own claims and want to stop funding the errors inside them, and the brokers who place and renew those groups. It is built just as deliberately for the two groups who never get a vote: members, who get straight answers about their benefits, and providers, who get paid promptly with far less back and forth.

Question 3

You are new. Why would anyone trust you with a health plan?

Accepted Answer

Fair question, and we are not going to talk around it. We are early, there is no wall of client logos on this site, and we are onboarding our first groups now. That is exactly why the first step is a rerun of your own claims file and the second is a parallel run against your current administrator. You are not asked to take anything here on faith. You are asked to compare two numbers computed on data you already own, and to keep the report whichever way it comes out.

Question 4

How does the claims rerun work?

Accepted Answer

You send a claims extract, a standard file your current TPA, carrier, or clearinghouse already produces on request. We reprice every line through our pricing engine and pass-through pharmacy model and return a line-by-line report showing what the same claims would have cost here, medical and pharmacy itemized. It carries no cost and no obligation, you keep the report either way, and if the difference is not worth the disruption of switching we will say so in writing.

Question 5

Do I need to migrate any data to start?

Accepted Answer

No. The rerun needs one claims file. Nothing connects to your systems, no integration work happens, and your current plan keeps running untouched throughout. The same is true of the parallel run that follows it, which processes copies of live claims alongside your incumbent rather than instead of them.

Question 6

Do I have to leave my broker?

Accepted Answer

No, and we would rather you did not. Brokers place and renew most of the groups we work with. Yours keeps the relationship and the compensation, and gets CAA-compliant disclosure and co-branded reporting that make the renewal conversation easier rather than harder.

Question 7

What does auto-adjudication mean?

Accepted Answer

It means a claim goes from intake to payment determination without a human touching it. The rules engine applies plan benefits, fee schedules, deductibles, copays, coinsurance, and out-of-pocket maximums automatically. Only claims that trip an exception rule stop for manual review, and those arrive at a person with the reason already attached.

Question 8

What is your auto-adjudication rate?

Accepted Answer

The platform is designed to auto-adjudicate 85 to 95 percent of clean claims depending on plan complexity and claim mix. That range is a design target rather than a measured result across a book of business, and we describe it that way on purpose. The high end comes from layering automated edit checks (coding validation, modifier checks, NCCI and MUE screens) on top of the deterministic rules engine, which is work that rules-only legacy systems skip or apply inconsistently. Your rerun report shows the rate the engine actually achieved on your own file.

Question 9

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 deductible and out-of-pocket accumulators. That automation is why administration costs less and reporting is current. Administrative determinations (eligibility, covered terms, duplicates, timely filing) follow the plan document exactly and route to a person when anything falls outside it. Medical-necessity decisions are never automated. Prior authorization and clinical review run through an independent URAC-accredited utilization management partner, appeals are heard by reviewers who had no part in the original decision, and independent external review applies where the situation calls for it. Every denial states its reason in plain language and explains how to appeal.

Question 10

How fast is adjudication?

Accepted Answer

Under two seconds per claim on average, and that figure covers the whole pass: eligibility verification, fee schedule lookup, benefit application, accumulator updates, and result generation. Speed matters here less as a feature than as a symptom, because a system that answers in two seconds is one where the plan is codified as data rather than living in an examiner's memory.

Question 11

What happens to the claims that do not auto-adjudicate?

Accepted Answer

They route to a person with the reason code, the plan language that applies, and a recommended determination already populated. The goal of automation here is not to remove the examiner, it is to make sure the examiner only sees the claims that genuinely need judgment rather than the several thousand that do not.

Question 12

What denial codes do you support?

Accepted Answer

The full CARC (Claim Adjustment Reason Code) and RARC (Remittance Advice Remark Code) sets required by X12 835 transactions. Common reasons include timely filing (CARC 29), non-covered services (CARC 96), and duplicate claims (CARC 18). Providers get the code and the plain-language reason together, which is what removes most of the phone calls.

Question 13

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, with no spread and no hidden markup on any prescription. Rebates are reported, the PBM bills your plan directly so pharmacy dollars never route through our books, and medical and pharmacy deductibles stay in sync so members are never overcharged at the counter.

Question 14

What is a pass-through PBM?

Accepted Answer

One that charges the plan exactly what it reimburses the pharmacy and earns its revenue from a disclosed per-member or per-claim fee. Traditional PBMs profit from spread, meaning they bill the plan more than they pay the pharmacy and keep the difference, and from retaining rebates. The pass-through model removes both incentives, which is the reason we require it of our pharmacy partner rather than treating it as an upgrade.

Question 15

What is reference-based pricing?

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 discount off an inflated billed charge. There is no network, so members can see any provider. SmartTPA offers it as a plan design option, with claim repricing, provider engagement, and member balance-bill defense handled through an established partner.

Question 16

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

Accepted Answer

Both, and reference-based pricing is an option rather than a house position. Employers who prefer a traditional design run a PPO network plan on the same platform, where the adjudication engine applies network contract rates automatically the same way it applies any fee schedule. Your broker can quote either design, or compare both, in one proposal.

Question 17

What happens if a member gets a balance bill under reference-based pricing?

Accepted Answer

Balance-bill support is part of the plan design rather than something 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 provide legal defense where it is needed. Members are supported through the whole process and coached never to simply pay the bill.

Question 18

Do you offer utilization management and case management?

Accepted Answer

Yes, through independent URAC-accredited clinical partners: prior authorization, concurrent review, and large-case management. External appeal reviews go to a separate independent review organization, never the organization that made the initial determination, because a review by the original decision-maker is not a review. The platform also flags high-cost claimants early from live claims data, so case management can start while it still changes the outcome.

Question 19

How does SmartTPA lower total plan spend?

Accepted Answer

Three levers, listed in the order they reliably pay off. Pay claims correctly the first time, since coding validation and pre-payment edits catch the 5 to 10 percent of claims the industry mispays before the money leaves rather than chasing it afterward through a recovery vendor that keeps a share. Remove the spread from pharmacy with a pass-through PBM. Remove the margin from administration, so one disclosed fee is the whole of what we earn and it does not grow when your plan spends more. A reference-based design and stop-loss alignment add to that where they fit. None of it depends on members using less care.

Question 20

Switching administrators sounds like a nightmare. Is it?

Accepted Answer

It is the real reason most plans stay where they are, and pretending otherwise would not help you. What we can do is make sure you have evidence before you take the risk. The rerun is a file and touches nothing. The parallel run processes copies of live claims alongside your current administrator, so you watch both answers on the same claims for as long as you want. Your incumbent keeps paying claims the entire time, and only the third step moves the plan.

Question 21

How long does implementation take?

Accepted Answer

It depends on plan complexity, how clean the census is, and how quickly EDI connections can be established with your clearinghouse, so an honest answer is that we scope it with you rather than quote a number here. What we can say is what removes the usual delay: the platform reads your plan document and drafts the benefit configuration instead of someone hand-keying it, and the configuration is proved against test claims before a real claim is processed.

Question 22

What happens to claims still in flight when we switch?

Accepted Answer

That is the run-out decision and it gets made before a go-live date is set, not after. Either your prior administrator continues adjudicating claims incurred before the transition for an agreed period, or the liability transfers and we process them. Both are workable and they have different cost and continuity trade-offs, so it belongs in the implementation plan rather than in a footnote.

Question 23

Will members notice the change?

Accepted Answer

They will get new ID cards and a new portal, and that is the part worth planning carefully. What should not change is a member's ability to see their provider or fill a prescription on day one, which is why eligibility loads and pharmacy connectivity are verified before go-live rather than discovered on it.

Question 24

What EDI transactions do you support?

Accepted Answer

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

Question 25

Do I need a clearinghouse?

Accepted Answer

SmartTPA works with the clearinghouse you already use, or connects directly to payers. The EDI pipeline handles parsing, validation, and generation natively rather than through a bolted-on translator, so there is no middleware layer to license, monitor, or blame.

Question 26

Can I integrate with my existing systems?

Accepted Answer

Yes. There is a full REST API for practice management systems, billing platforms, payroll and HRIS feeds, and reporting tools. Your claims data is yours and it is exportable in standard formats whenever you want it, not on request.

Question 27

Is SmartTPA HIPAA aligned?

Accepted Answer

Yes, and built to the 2026 HIPAA Security Rule specifically, which eliminated the addressable category and made every safeguard mandatory. AES-256 encryption at rest, TLS 1.2+ in transit, multi-factor authentication, immutable audit logs, and 7-year retention, plus field-level encryption on the most sensitive data. Platforms designed before the cloud are retrofitting these, and retrofitting encryption into a system that was not built for it leaves gaps that surface during an audit.

Question 28

Where does SOC 2 stand?

Accepted Answer

Type II is in progress. We write in progress because that is where it is, and an administrator who blurs an unfinished audit is telling you something about the rest of its answers. Encryption at rest and in transit, immutable audit logging, and least-privilege access controls are running now. We share detailed security documentation and sign BAAs during evaluation.

Question 29

Where is SmartTPA hosted?

Accepted Answer

On AWS as a fully managed service, with a multi-AZ database, automated failover, and KMS-managed encryption keys. We operate the infrastructure ourselves, which is how every HIPAA control stays verifiable, auditable, and identical for every plan we administer. Your data is exportable in standard formats at any time.

Question 30

How long are audit logs retained?

Accepted Answer

Seven years, in immutable append-only storage. Every access, modification, and system event is recorded with timestamp, user, and IP address. The point is not the retention period, it is that when someone asks why a claim paid the way it did, the answer is a record rather than a recollection.

Question 31

How do you charge?

Accepted Answer

One transparent administrative fee, disclosed in full, with pricing shared in direct conversation and in the signed agreement. Every group's size, plan design, and claim volume differ enough that a number posted on a website would be wrong for almost everyone reading it. The rerun of your claims carries no cost and no obligation.

Question 32

Are there hidden fees?

Accepted Answer

No. No per-claim surcharges, no spread pricing, no claim-editing markups, no out-of-network repricing markup, and no vendor compensation buried inside the plan's own spend. CAA-compliant compensation disclosure comes with every engagement. The structural version of this promise is that what we earn does not increase when your plan spends more.

Question 33

How many ways does SmartTPA make money from our plan?

Accepted Answer

One: the administrative fee. There are nine meaningful revenue lines available to a third-party administrator, and the other eight all grow when your plan spends more. We take none of them. No pharmacy spread, because an independent pass-through PBM bills you directly and those dollars never touch our books. No retained rebates. No network access rebate. No contingency fee on post-payment recoveries, which is the arrangement that quietly prefers errors to exist. No out-of-network repricing markup. No per-transaction surcharges. No float, because your claim funding stays with you until claims are paid. No commission from any partner we contract. Our guide on how TPAs make money lists all nine with the question that surfaces each one, and it is written so you can use it on us.

Question 34

Who pays for subrogation, and do you take a cut of it?

Accepted Answer

An independent firm pursues recoveries from a liable third party, whether that is an auto insurer, a workers' compensation carrier, or another health plan, and it takes a contingency out of what it recovers. You can pick that firm yourself, and if you would rather we propose one, your written approval is required before any file is referred. You see that rate up front, it passes through to the plan at cost, and we keep none of it: no referral fee, no override, no markup. We also charge nothing to recover our own payment errors, because an administrator that profits from fixing its own mistakes has the wrong incentive. The structure is the same one we use for pharmacy: the specialist is paid for the specialist work, we are paid the administrative fee, and nothing else routes through us.

Question 35

What if I want to cancel?

Accepted Answer

The rerun carries no cost and no obligation and 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 rather than implied here. Whenever the relationship ends, we help you export your data in standard formats. Your data is never the thing that keeps you.

Answers to the questions we hear most.

Getting Started

Claims & Adjudication

Pharmacy & Cost Control

Switching & Implementation

EDI & Integrations

Compliance & Security

Fees & Engagement

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