Currently TPAs manually generate reports when claims surpass stop-loss limits. This requires a ton of manual effort to assemble the relevant data and documents. Meanwhile, stop-loss providers wait weeks before they can start evaluating these claims, leading to worse economic and patient outcomes.

With Amera, TPAs can instantly ingest carrier contracts, identify relevant claims, enrich with case management and PBM data, and show exactly what documentation is needed for submission, all without an extra team of people who could be working on more valuable activities.

Amera ingests the stop-loss contract, continuously monitors claims activity, and tells the TPA team:

• Which members are approaching or exceeding the deductible (with diagnosis, Rx, and case management context)

• What’s eligible for reimbursement and the exact documentation required

• How the plan is tracking toward the aggregate attachment point (claims, enrollment, lag validation)

• Which claimants and drugs are likely to drive lasers and renewal risk

We’re seeing teams go from weeks of back-and-forth and document chasing to having everything ready for submission in seconds with fewer carrier rejections and faster recovery.

Results: Recovery time reduced from 2+ weeks to seconds, fewer carrier rejections, and a team focused on complex cases instead of data compilation