TPA administration platform — every feature, with a watch-it button.
A claim only adjudicates if the member is eligible on the service date.
▶ Watch demoThe allowed amount is the lowest available basis; here the reference (RBP) wins.
▶ Watch demoA service with a copay charges the copay as the member's whole cost-share for that line.
▶ Watch demoWith a fresh deductible the full allowed applies to the member's deductible.
▶ Watch demoOnce the deductible is met, the plan's coinsurance % splits the remainder.
▶ Watch demoMember coinsurance is capped at remaining OOP; past the OOP max the plan pays 100%.
▶ Watch demoA high deductible can never push the member past their OOP max.
▶ Watch demoRemaining = min(individual, family); whichever cap is closer stops the member's spend.
▶ Watch demoRx claims draw a separate Rx deductible/OOP with their own copays.
▶ Watch demoOn an INTEGRATED plan, Rx cost-share draws the medical deductible/OOP.
▶ Watch demoWith no pricing basis the line is PENDED with a reason code — never zeroed or paid at billed.
▶ Watch demoWithin one claim, line 1's deductible spend reduces line 2's remaining deductible.
▶ Watch demoEvery result carries an audit envelope (accumulators before/after) and is reproducible.
▶ Watch demoA member-facing Explanation of Benefits with per-line and total splits ('not a bill').
▶ Watch demoAn instruction the Billing money backbone books; tpa-admin never books money itself.
▶ Watch demoWhen plan-paid crosses the spec attachment point, a stop-loss signal is emitted to MGU.
▶ Watch demoA JSON claims file plugs into the identical pipeline via the ClaimSource port.
▶ Watch demoAccumulators persist across runs/processes so deductible & OOP carry over.
▶ Watch demoWhen a line carries no price, the rates/repricing/pharmacy adapters supply it.
▶ Watch demoAccumulator year comes from the plan's start month, so YTD doesn't reset mid-plan-year.
▶ Watch demoA denied claim can be appealed; an OVERTURNED appeal FLAGS the claim for re-adjudication and NEVER auto-pays — money stays human-in-command.
▶ Watch demoThe 180-day appeal clock runs from the immutable, recorded member-NOTICE date — not a forgeable caller date; file_appeal consults the notice store and refuses a silent bypass.
▶ Watch demoPHI stays in-boundary: direct identifiers become stable OPAQUE tokens, dates -> year, ZIP -> 3 digits, free text dropped; only de-identified data crosses to external AI; the vault re-associates server-side.
▶ Watch demoEvery EDI intake is audited; a same-CLM01 PARTIAL resubmit (stranded pended lines) is SURFACED as partial_reopen — never silently dropped — and --audit-summary exits non-zero so cron can alert ops on what needs action.
▶ Watch demo