Health Insurance Claims and TPA Management

Claims and the relationship with the insurer or third-party administrator are where a medical scheme is tested. This program covers how claims flow, how to work effectively with a TPA, and how to resolve disputes.

Participants learn to manage the claims process on behalf of employees, monitor performance, and hold the administrator accountable to the service standards agreed.

By the end of this course, participants will be able to:

– Describe the end-to-end claims process
– Explain the role of the TPA and the insurer
– Manage pre-authorization and approvals
– Track and reconcile claims activity
– Resolve rejected or disputed claims
– Monitor TPA service levels and performance
– Support employees through claims issues

1- The Claims Process End to End
2- Roles of the Insurer and TPA
3- Pre-Authorization and Approvals
4- Cashless and Reimbursement Claims
5- Documentation Requirements
6- Claim Rejections and Common Causes
7- Disputes, Appeals and Escalation
8- Handling Complex and High-Cost Claims
9- Reconciliation and Reporting
10- Monitoring TPA Performance and SLAs
11- Identifying Trends and Cost Drivers
12- Supporting Employees Through Claims

HR and benefits staff who manage medical claims and the relationship with the insurer or TPA.

The program uses claims case studies, sample rejection scenarios, and a service-level review exercise. Participants practice dispute resolution and performance monitoring across the week, finishing with a case clinic.

Participants leave able to manage claims confidently, resolve disputes, and hold the administrator to the agreed standard of service.