What does a TPA check run need before finance releases it?

What is a TPA check run in self-funded plan funding?

A TPA check run is the designated time when an administrator issues payments for approved claims. In self-funded plan funding, the money belongs to the employer. The process begins with a funding request, the TPA's statement of what the plan owes for the current batch of claims.

The employer then funds this request, typically via wire transfer. Once funded, the TPA releases payments as physical checks or electronic funds transfers. Because the run is the exact moment the plan's money leaves the account, correcting mistakes post-release requires difficult recoveries or overpayment letters.

Key Takeaways:

• A check run commits the employer's funds to pay adjudicated claims.
• Mistakes caught before the run are simple corrections; mistakes caught after require complex recoveries.
• Finance teams must carefully review the run before authorizing the release.

Why is a precise funding request wire match critical?

A funding request wire match is mandatory because the TPA is distributing funds the employer specifically sent for that exact batch. Any discrepancy means the TPA is either paying claims the employer did not fund or holding excess money. Both scenarios present severe audit risks and must be documented before release.

Differences happen for standard operational reasons. A claim might be voided after the funding request was issued, or the employer might combine an administrative fee invoice with the claim wire. These variances are harmless if identified before the TPA finance release. Finance teams must match the request to the wire line-by-line and document every difference.

Key Takeaways:

• The employer's wire must perfectly match the TPA's funding request.
• Common differences include voids, reissues, and netted fees.
• Documenting variances line-by-line prevents compliance issues after payments clear.

What must the payment register show for claims check run reconciliation?

The payment register acts as the central ledger for claims check run reconciliation. It must detail every payment, including the payee, payment amount, specific claims covered, group identifiers, and payment method. The final total must equal the funded amount after accounting for documented variances.

A reliable payment register passes three primary checks. First, every claim must sit in a paid-approved status, verified by an examiner. Second, the payee details must align with the provider's current record to prevent bounced electronic transfers or lost checks. Finally, in-contract claims must display exact payment terms, removing the need for account managers to memorize prompt-payment rules.

Key Takeaways:

• The register must tie directly to the approved claims and the final funded amount.
• Claims must be in a released, paid-approved status with no duplicates.
• Payee data must be current to ensure successful payment delivery.

How does 835 remittance preparation impact providers?

Proper 835 remittance preparation is vital because these electronic files tell healthcare providers exactly what was paid, adjusted, or denied. Providers relying on electronic payments expect the 835 file to arrive alongside or before the funds. Their billing teams use these files to automatically apply payments to patient accounts.

A payment sent without a matching 835 file creates immediate posting errors for the provider and triggers support calls to the TPA. Before finance releases the batch, these files must be generated directly from the payment register to guarantee a perfect match. Finance teams do not need to read every 835, but they must confirm the files are prepped and reconciled.

Key Takeaways:

• 835 files explain payment adjustments directly to provider billing systems.
• Generating 835s from the payment register ensures exact payment matching.
• Missing or mismatched remittances lead to provider friction and support calls.

When is stop-loss notice tracking required during a check run?

Stop-loss notice tracking is required when a claimant's accumulated paid claims approach their specific policy limits. Many stop-loss policies require the employer to submit proof-of-loss forms within 30 days of becoming aware of facts suggesting that covered expenses will be incurred that "are equal to or exceed 50% of the specific deductible." If a TPA misses this notice, the failure "may result in the rescission of the terms of the stop loss insurance policy."

The check run is the mechanism that pushes claimants over these thresholds. Consequently, the run must include a step that recalculates each claimant's totals with the new batch's data. Before release, the finance team needs a clear list of claimants crossing thresholds and confirmation that required notices are queued.

Key Takeaways:

• Stop-loss carriers require immediate notice when deductibles approach policy limits.
• The check run calculates the new totals that trigger these mandatory alerts.
• Missing a threshold alert can jeopardize employer reimbursements.

How does Daybook automate the TPA check run?

Daybook Health prepares the entire check run so the finance team only has to handle the final release. Transitioning from adjudication to the check run in a self-funded plan requires meticulous data alignment. Daybook matches the funding request to the wire, builds the register, handles 835 preparation, and flags stop-loss notices automatically.

The platform provides reconciliation work agents prepare and people release. The AI agent reads the bank's wire record, contrasts it against the claims system, and flags any un-reconciled items. Daybook's software handles the tedious matching, allowing the TPA's human experts to simply review the flags and make the financial decision.

TPA Check Run Process Comparison

Key Takeaways:

• Daybook automates wire matching, register building, and 835 generation.
• AI agents highlight discrepancies for human review.
• Human finance teams retain total control over the final release decision.

Who authorizes the TPA finance release?

The TPA finance release must be authorized by a named individual on the finance team. Software and automated claims systems never release the money. A human signs off, and that signature serves as the final, stamped entry in the batch's permanent record.

Standard internal controls demand a strict segregation of duties between the examiners adjudicating claims and the finance personnel releasing funds, separating "the responsibilities for authorizing transactions, processing and recording them, reviewing the transactions, and handling any related assets so that no one individual controls all key aspects of a transaction or event." That principle comes from GAO's Standards for Internal Control in the Federal Government, which is mandatory for federal executive branch entities and is offered to other entities as a framework they may adopt. A well-prepared check run record includes the wire matching, the reconciled register, generated 835s, stop-loss checks, resolved flags, and the releasing agent's signature. This complete audit trail is what plan sponsors and stop-loss carriers expect to see during reviews.

Key Takeaways:

• Only a named human finance professional authorizes the release of funds.
• Segregation of duties prevents claims adjudicators from releasing payments.
• A robust check run record provides a complete audit trail for plan sponsors.