The Problem
You're spending hours each week untangling claim disputes, reacting to compliance findings, or rebuilding processes that should already be standardized. The lack of a unified framework for TPA governance and claims oversight is costing you time, increasing risk, and slowing down decision-making. This playbook eliminates that chaos by giving you a proven structure used in top-performing claims organizations.
What You Get
12-Module Mastery Course , Build Expertise Step by Step
- Foundations of Claims Management and TPA Oversight
- Regulatory Landscape: ERISA, HIPAA, State Mandates, and CMS Rules
- Designing a TPA Governance Model with Clear Accountability
- Claims Audit Protocols and Compliance Validation
- Operational Risk Assessment in Third-Party Administration
- Performance Monitoring: SLAs, KPIs, and Escalation Triggers
- Claims Data Integrity and System Interoperability
- Grievance and Appeals Management Framework
Ready-to-Use Implementation Toolkit , 10 Key Files You Need Now
- ✅ TPA Governance Maturity Assessment with Scoring Rubric
- ✅ Claims Compliance Gap Analysis Template (ERISA, HIPAA, 45 CFR Part 158)
- ✅ TPA Selection Decision Framework with Weighted Criteria
- ✅ Claims Operations Implementation Roadmap (90-180-365 Day Plan)
- ✅ Stakeholder Accountability Map for Claims Oversight
- ✅ Claims Process Runbook with Handoff Triggers and Escalation Paths
- ✅ Actuarial Risk Exposure Matrix with Severity Scoring
- ✅ Regulatory Audit Readiness Checklist (NCQA, DOL, State DOI)
- ✅ Claims Quality Assurance Scorecard with Defect Tracking
- ✅ KPI Dashboard for TPA Performance (SLA Compliance, P2P Time, Error Rate)
- ✅ Contractual Safeguards Reference Registry (Amendment Tracking)
- ✅ Claims Data Governance Policy Template with Access Controls
How It Is Organized
Start with the course to build a complete, structured understanding of claims management and TPA governance. Each module builds on the last, moving from regulatory foundations to advanced risk oversight. Once you've completed the relevant sections, go straight to the toolkit to implement what you've learned. The 10 practitioner journey folders guide you from setup to sustainability: Getting Started gives you onboarding checklists, Assessment & Planning includes maturity models and gap tools, Models & Frameworks delivers decision logic and governance charts, Processes & Handoffs standardizes workflows, Operations & Execution provides runbooks and tracking, Performance & KPIs offers dashboards and SLA monitors, Quality & Compliance ensures audit readiness, Sustainment & Support includes training aids and version control, Advanced Topics covers complex claims scenarios and vendor disputes, and Reference houses regulatory citations and contract language you can reuse.
This Is For You If
- You have been asked to build a TPA governance program from scratch and need to show a plan by next quarter
- You're auditing claims processes and keep finding the same compliance gaps across vendors
- You're preparing for a DOL or state regulator audit and don't have a centralized compliance file
- You're onboarding a new TPA and need a structured way to validate their controls and reporting
- You're tired of reinventing templates every time a new risk or regulation emerges
What Makes This Different
The course gives you the structured knowledge, the toolkit gives you the implementation files. Together, they cover the full journey from learning to doing, so you're not left guessing how to apply concepts in real operations.
Every template is ready to fill in today, not theoretical. The Pro Tips sections contain hard-won lessons from real implementations, like how to negotiate audit rights with TPAs or which KPIs actually predict claims leakage.
Built by a team with 25 years in this exact domain, this is not a repackaged generic framework. You get the complete system, tested in health plans, third-party administrators, and large self-insured employers, so you don't waste time piecing together fragments from consultants or outdated guidance.
Get Started Today
This playbook gives you a complete, proven system: structured learning that builds real expertise, and implementation files you can adapt and deploy immediately. Skip months of research, template drafting, and stakeholder alignment from scratch. Focus on execution, reduce compliance risk, and establish credible oversight of your claims operations from day one.
