Insurance Plan Enrollment

• Managing an employer's insurance enrollment is one of the primary functions of a TPA. TPAs coordinate the entire open and ongoing enrollment process. From getting employees signed up for benefit programs, either online or through forms, to sending the enrollment information to the insurance carriers, TPAs administer the entire process. TPAs manage ongoing enrollment changes including additions, terminations and changes and transmit this information, usually through electronic file transmissions, to the employer's medical, dental and other benefit programs.
  
  

COBRA Administration

• The Consolidated Omnibus Budget Reconciliation Act, commonly called COBRA, ensures that employees who terminate from their jobs, voluntarily or involuntarily, are offered continuation of their group health insurance. TPAs are responsible for notification of COBRA benefits to newly terminated employees. TPAs must meet the regulatory guidelines set forth in Act, such as sending out notification within 14 days of notification from the employer. In addition, the TPA manages the enrollment process and transmits the COBRA enrollee data to the medical and dental carriers. Many TPAs also handle the billing to employees and premium collection.
  
  

Technology

• In addition to managing the enrollment process, TPAs maintain a database of employees' enrollment data. This database produces useful reports for employers, such as employee rosters showing their staffs' addresses, Social Security numbers and dependent names. Additionally, TPAs may set up a website for employees and employers to access their benefit information. The website is a self-service tool that shows benefit selections; specific benefits covered and plan details and claims history, if the TPA also manages claims.
  
  

Claims Administration

• Claims administration is another typical function of a TPA. TPAs may handle claims submission, where claims are submitted directly to the TPA. Claims may get scanned and input into the TPAs' system for adjudication and payment. TPAs that manage claims also offer claims customer service, for providers and employees to inquire about claims. Access to claims data allows the TPA to provide the employee with many reports such as utilization by procedure and service, claims costs and large claim management. Additionally, TPAs send out Explanation of Benefit statements to employees that outline how claims were paid for a particular date of service and procedure.