Most claims problems are seams between systems.
Adjudication, eligibility, EDI, portals, and compliance are one system here. There is no nightly handoff to arrive late, no middleware to fail quietly at 2am, and no second vendor to point at when a claim goes missing.
Illustrative product view of the SmartTPA claims dashboard.
- 2026 HIPAA Security RuleBuilt to it, not retrofitted
- AES-256 encryptionAt rest and in transit
- Immutable audit logs7-year retention
- SOC 2 Type IIIn progress, and we say so
- Clearinghouse-ready EDIClaims in, remittances out
What it does
Four jobs, one platform, no integration project.
Claims finalize, or they tell you why
A deterministic rules engine with automated coding validation on top. It applies plan benefits, fee schedules, accumulators, and coordination of benefits in under two seconds, and it finalizes clean claims that rules-only systems would park in a queue for a person to look at next week.
- Coding errors and upcoding caught before payment, not clawed back after
- Fee schedule and network rate lookups applied automatically
- Coordination of benefits detected rather than discovered later
- Accumulators updated as the claim finalizes, so the next one prices correctly
- Exceptions routed to a person with the reason attached
Claims arrive and remittances leave, without middleware
Electronic claims exchange is native rather than a translator bolted to the side. Claims flow in from your clearinghouse, remittances flow back to providers, and eligibility is answered while the patient is still at the desk. Most claims problems are seams between systems, so we removed the seam.
- Claims intake from any clearinghouse, or direct payer connections
- Electronic remittance back to providers with readable reason codes
- Real-time eligibility responses instead of a nightly batch
- Claim status answered electronically rather than by phone
- No nightly file to arrive late and strand a day of claims
The questions stop reaching your HR team
Members check benefits, estimate what care will cost before they get it, and ask questions in plain language against their own plan document. Employers watch spend as it happens. Self-service only counts if it answers the question the person actually had.
- Cost estimates built from real provider rates, before care
- Live deductible, out-of-pocket, and accumulator status
- An assistant grounded in the member's own plan, not a generic chatbot
- Digital ID cards and full EOB history
- Employer dashboard with live metrics and co-branded broker reporting
The evidence exists before anyone asks for it
Built to the 2026 HIPAA Security Rule, which removed the addressable category and made every safeguard mandatory. Retrofitting encryption and audit controls into a platform that was not designed for them leaves gaps, and those gaps surface during an audit rather than before one.
- Encryption at rest and in transit on every record
- Field-level encryption on the most sensitive data
- Multi-factor authentication on all administrative access
- Immutable audit logs retained seven years
- Every access to protected data recorded and reviewable
The path of a claim
Received to determined, in under two seconds.
Intake
Claims arrive electronically from your clearinghouse or by direct upload, then get parsed, validated, and matched to member and provider records.
Validation
Coding, medical policy, and anomaly checks run before a dollar moves. Clean claims continue without stopping.
Adjudication
The rules engine applies plan benefits, fee schedules, deductibles, copays, and coordination of benefits, then finalizes or routes the exception with a reason.
Remittance
Payment detail goes back to the provider electronically, the member's EOB posts to the portal, and the employer dashboard updates, all in the same pass.
Member experience
A benefits question answered before it becomes an HR ticket.
Members get answers grounded in their own plan and their own accumulator status, which is the difference between a useful answer and a link to a PDF.
- What a procedure costs at a specific provider, before booking it
- Where the deductible and out-of-pocket maximum actually stand today
- An assistant reading the member's own plan document, not a generic bot
- Digital ID cards and EOB history on the phone they already carry
How much will my MRI cost at Mercy Hospital?
Mercy is in network for you. You have met about 57% of your deductible, so your share is the rest of the deductible plus your 20% coinsurance.
Anywhere in network that costs less?
Yes. Northside Imaging is 4.2 miles away, costs less for the same scan, and has same-week availability.
Illustrative exchange. The assistant answers from the member’s own plan document and live accumulator data.
Underneath
Built to stay up, and to keep protected data protected.
Every security setting is defined in code, which means it can be reviewed, reproduced, and audited rather than taken on trust.
Multi-AZ cloud database with automated failover and encrypted backups
Encryption at rest and in transit on every record
An immutable seven-year audit trail on every access to protected data
Security analysis on every release, with regressions blocked before they ship
Infrastructure managed as code, so every control is reviewable and reproducible
Sub-two-second adjudication that holds as your group grows
See it on your own data
Test the claims here against yours.
Open the demo with synthetic data, or send a claims file and we will reprice every line and show you the difference.