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Five vendors blaming each other, or one number to call.

Claims, pharmacy, clinical review, COBRA, stop-loss, and compliance run on one system with one accountable party. Where a specialist genuinely does it better we contract one, hold them to the same disclosure standard, and take no margin on their work.

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  • 2026 HIPAA Security Rule
    Built to it, not retrofitted
  • AES-256 encryption
    At rest and in transit
  • Immutable audit logs
    7-year retention
  • SOC 2 Type II
    In progress, and we say so
  • Clearinghouse-ready EDI
    Claims in, remittances out

The nine

Nine services, one system, one accountable partner.

Claims Administration

Errors caught before the money leaves

A deterministic rules engine plus automated edit checks clear clean claims in under two seconds and catch the mispayments that drain a plan unnoticed. Prevention keeps the whole dollar. Post-payment recovery gets a fraction of it back and pays a contingency fee for the privilege.

  • Electronic claim intake through your clearinghouse
  • 85 to 95 percent auto-adjudication design target on clean claims
  • Fee schedule enforcement and coordination of benefits
  • Electronic remittances back to providers
  • Appeals and denial management with a person on every real exception

Pharmacy Benefits

The plan pays what the pharmacy was paid

Pharmacy is where hidden margin prefers to sit. Your Rx benefit runs through an independent pass-through PBM: the plan pays the pharmacy's price plus one disclosed fee, and the PBM bills your plan directly, so pharmacy dollars never route through our books at all.

  • Pass-through pricing with no spread on any prescription
  • Rebate transparency showing what was earned and where it went
  • Real-time adjudication at the pharmacy counter
  • Medical and pharmacy deductibles tracked as one and kept in sync
  • Low-cost sourcing, including cost-plus and warehouse pharmacies

Reference-Based Pricing

A published benchmark instead of a negotiated mystery

Available as a plan design option rather than a house position. Claims price from what Medicare pays for the same service instead of a discount off an inflated charge, which produces a number you can defend. 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, so members can see any provider
  • Balance-bill defense and member advocacy included, not sold separately
  • Provider engagement and dispute resolution handled for you
  • Can reduce stop-loss premiums at renewal

Utilization & Care Management

Nobody grades their own work

Prior authorization, concurrent review, and case management run through independent URAC-accredited clinical partners, and appeals go to a separate independent review organization. The reviewer who hears an appeal never made the original call, which is the structural reason an appeal means anything.

  • 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 on clinical appeals
  • High-cost claimants identified early from live claims data

COBRA Administration

Off your plate and audit-ready

Notices, premium collection, and qualifying-event tracking run automatically and stay DOL-audit-ready. The exposure here is not the administration, it is the missed deadline that turns a routine termination into a penalty nobody budgeted for.

  • Initial notice and qualifying event letters
  • Premium invoicing and collection
  • Coverage termination tracking
  • HIPAA-compliant member records
  • DOL audit-ready reporting

Stop-Loss Coordination

Recoveries that actually get collected

Working with your broker and licensed stop-loss partners, we coordinate specific and aggregate coverage, then track triggers against live claims and file reimbursements automatically. An unfiled recovery is indistinguishable from a claim you were never owed.

  • Specific and aggregate stop-loss coordination
  • Quote coordination across multiple carriers
  • Laser negotiation support
  • Automatic trigger tracking against live claims
  • Reimbursement filing

Compliance & Reporting

The filings that keep 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 rather than bolted on after a breach. The plan sponsor carries the fiduciary duty, so the evidence has to exist before anyone asks for it.

  • Plan document drafting and updates
  • Form 5500 preparation
  • ACA reporting, 1094 and 1095
  • HIPAA training and policies
  • Immutable 7-year audit logs

Eligibility & Enrollment

Current, not batched

Census, life-event changes, and dependent verification stay in sync automatically. Real-time eligibility means a provider knows what is covered before the patient is in the chair, and a terminated member is not still covered on paper for the rest of the week.

  • Census import and validation
  • Life event and change tracking
  • Dependent verification
  • Real-time 270/271 eligibility responses
  • Member ID card generation

Employer Reporting

In time to act on it

Live dashboards for spend, utilization, and high-cost claimants, with anomaly alerts the moment a pattern emerges. A number that arrives 30 days late can be filed but not used, and the difference between those two things is the entire point of reporting.

  • Real-time spend and utilization dashboards
  • Demographic and claim pattern analytics
  • High-cost claimant identification
  • Benchmark comparisons
  • Export to any BI tool

Implementation

You confirm the configuration. You do not dictate it into someone else’s system.

The usual implementation is weeks of someone hand-keying your plan document into a legacy platform, and every keystroke is a chance to get a benefit wrong. The platform reads the plan, drafts the configuration, and proves it against test claims before a real claim is processed.

  1. 1
    Kickoff

    Agreement signed

    You sign the services agreement and we provision your tenant.

  2. 2
    Upload

    Plan document uploaded

    Upload the SPD and census. The platform reads the plan and drafts the benefit configuration.

  3. 3
    Review

    Configuration confirmed

    You review and confirm what was extracted. Corrections are a configuration change, not a development ticket.

  4. 4
    Connect

    EDI connections established

    Clearinghouse or direct payer connections tested end to end, with real-time eligibility verified against live responses.

  5. 5
    Prove

    Test claims run

    The configuration is exercised against test claims and you see the determinations before a real claim is processed.

  6. 6
    Go live

    Live claims processing

    Claims flowing, dashboards populated, members onboarded.

Priced to your plan

Get a proposal tailored to your group.

Tell us your group size, current spend, and where it hurts. We send a proposal within 2 business days.

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