Healthcare third party administrators (TPAs) manage complex administrative functions that demand accuracy, speed & regulatory compliance. Fusion CX supports TPAs with outsourced enrollment, claims administration, member & provider services, operating within client-approved workflows and delegated responsibilities.
Our experienced healthcare professionals manage critical administrative work for TPAs, health plans and insurance administrators, from enrollment and billing and claims support to customer and member services. Our healthcare TPA service solutions are designed to simplify healthcare administration while enabling TPAs to focus on managing health plans, improving outcomes and supporting members throughout their healthcare journey.
With over 22 years of experience, Fusion CX pairs advanced technology with a skilled workforce and multilingual, omnichannel delivery, helping TPAs optimize operations, lift member satisfaction and support operational consistency and adherence to applicable requirements within the contracted scope.
Enrollment and billing, claims support and member services, delivered as one program or service by service.
Support employer-group enrollment, eligibility updates, dependent changes & member onboarding under client-defined plan rules. Retain Medicare separately only where relevant.
Help members navigate enrollment requirements and access information through multilingual assistance and approved escalation pathways.
Timely, accurate billing, payment posting and account reconciliation, backed by automated enrollment and billing integration that reduces manual work.
Support claims intake, completeness checks, processing queues, and exception follow-up under client-defined rules. Escalate discretionary decisions to authorized client personnel.
Manage claims-status inquiries, outstanding documentation follow-up, and payment reconciliation within agreed responsibilities.
Responsive, multilingual support through a 24/7 healthcare call center that answers member inquiries quickly and professionally.
Support administrative care navigation, provider communication, and approved outreach, with clinical questions escalated to designated clinical teams.
Support inquiries using client-approved policies and scripts, escalating regulatory interpretation and complex cases to the client’s compliance team.
A TPA’s volume grows one plan sponsor at a time. Our program is built to absorb each new group without disrupting the ones you already serve.
Plan documents, eligibility file layouts, networks, ID card timelines and service levels are captured for each new employer group well before its effective date.
Enrollment files are validated, agents are certified on the new plan and extra seats cover the welcome calls and ID card questions that follow launch.
Claims, premium billing and reconciliation move onto shared procedures, with group-specific rules documented so any trained agent can handle them.
Annual plan changes, new regulations and sponsor requests are loaded into scripts and training ahead of renewal, keeping answers accurate year to year.
Trainable GenAI voice agents automate routine eligibility, ID card and claim status calls, cutting contact center costs with a clean handoff to agents.
Automated audits and compliance checks on enrollment, claims and member calls improve TPA accuracy and catch errors before they reach a plan sponsor.
Analyzes authorized interactions to identify recurring service issues, with access and reporting restricted according to client permissions and employer-group requirements.
End-to-end coverage, room to grow and the controls a regulated administrator needs.
End-to-end services, including claims processing, enrollment support and care coordination, tailored for TPAs.
Customized workflows and scalable capacity that help TPAs grow their book of business efficiently.
Support in 28 languages across phone, email, chat and SMS for diverse member populations.
AI and automation that streamline workflows, reduce costs and improve accuracy in TPA operations.
Applicable BAAs, role-based access, identity-verification procedures, and audit trails support PHI handling within approved workflows. Present verified certifications separately.
40+ delivery centers in 13 countries keep member and claims support running through outages and peaks.
What happened when health plans and healthcare companies handed member and operations work to Fusion CX.
Tell us about the plans you administer, your member volumes and the functions you want to outsource. A healthcare CX specialist will follow up with a scope, ramp plan and pricing.
Perspectives for TPA leaders on regulation, member experience and enrollment.
The questions third party administrators ask us most often.
Healthcare third party administrators are organizations that manage administrative functions for health insurance plans, self-funded employers and healthcare programs. They handle claims processing, member services, provider support, eligibility verification, enrollment and benefits administration, helping improve operational efficiency and healthcare delivery.
Fusion CX offers comprehensive healthcare TPA services, including claims support, member and provider services, enrollment assistance, eligibility verification, benefits administration, prior authorization support, billing inquiries, care coordination and omnichannel customer service that improve operational performance.
A healthcare TPA call center gives members fast, personalized support for claims inquiries, benefits information, eligibility verification, enrollment assistance and provider coordination. That reduces wait times, improves first-contact resolution and delivers a better overall member experience.
Yes. Our healthcare TPA services include dedicated provider support for eligibility verification, claims status, prior authorization, referral assistance, billing inquiries and provider communication, ensuring seamless collaboration between providers and the health plans you administer.
Fusion CX combines AI-powered automation, intelligent IVR, omnichannel communication, CRM integration, workflow automation, speech analytics, workforce management and real-time reporting to optimize healthcare TPA services, improve operational efficiency and give TPAs clear visibility into every program.
With over 22 years of experience, Fusion CX delivers scalable healthcare TPA services backed by experienced healthcare professionals, AI-powered technology, HIPAA-compliant operations, multilingual support and omnichannel engagement. We help TPAs streamline operations, improve member and provider satisfaction, reduce costs and drive better healthcare outcomes.
