Standards for TPA claims processing

[Guest Carl Pilger]

Is anyone aware of an industry or national standard applicable to TPAs for the timeliness of group health claims processing under a self-insured plan? We are claiming that untimely processing resulted in self-funding claims that would have been covered by excess insurer. The TPA contract, however, did not establish a time certain within which claims would be processed. It merely stated that the claims would be processed "promptly" and "timely."

[KIP KRAUS]

Carl:

How long had these claims been in the hands of the TPA? I assume that the bills from providers were recieved by the TPA in a timely manner? I've seen hospitals take months to bill in some cases. Reasonable time to process claims that need no follow up information should be maximum five working days.

Not sure that independent TPAs are regulated as most insurer/TPAs are, but you may want to check with the state insurance department.

A preventative measure for the future might be to purchase a stop-loss contract with a 12/15 payment provision, which pays incurred in contract period paid in contract period plus 3 months. There shouldn't be a three month lag in incured claims in most cases.

Hope this helps some.