Portal/ Documentation/ TPA

TPAs — Third-Party Administrators

Processes insurance claims and handles administrative functions for self-funded employer health plans, health plans, or other payers. Unlike insurance companies, TPAs do not underwrite risk -- they administer the plan on behalf of the plan sponsor.

14
Primary Modules
7
Key API Integrations
9
Regulatory Requirements

Primary Portal Modules

Claims Enrollment Billing Auth Employer Groups Financial Providers Patient Grievances Compliance Documents Analytics Products Communication

Organizational Relationships

▲ Vertical — Reports To (Upward)
  • Self-funded employer plan sponsors (fiduciary)
  • State DOI (licensing)
  • DOL (ERISA oversight)
▼ Vertical — Oversees (Downward)
  • Claims processing teams
  • Member services
  • Utilization review staff
  • Subcontracted vendors (PPO networks, PBMs)
▶ Horizontal — Collaborates With (Peer)
  • Stop-loss carriers
  • PPO network rental companies
  • PBMs
  • MCOs (network access)
  • Brokers/consultants
  • Clearinghouses
  • Actuarial firms
  • Wellness vendors

Key API Integrations

  • Full X12 EDI Suite (837/835/834/820/270/271/276/277/278)
  • Provider network repricing APIs
  • Stop-loss carrier feeds
  • NCPDP Pharmacy
  • Banking/Payment APIs
  • Employer HR/Benefits Integration
  • CMS MSP Reporting

View Full API Guide →

Regulatory Requirements

  • State TPA licensing
  • ERISA compliance
  • HIPAA Privacy/Security/Transactions
  • ACA compliance
  • State prompt-pay laws
  • MHPAEA (Mental Health Parity)
  • No Surprises Act
  • COBRA administration
  • SOC 1/SOC 2 audits