One platform to administer every health plan client you serve — adjudication, X12 EDI, enrollment, and provider payments, with each client’s plan designs and data kept separate. Published pricing, and zero per-claim fees as you grow.
Ten systems most vendors sell separately for administering health plans across client groups — adjudication, EDI, enrollment, payments, and reporting all included.
Claims that meet a client’s plan rules process straight through without a keystroke. Anything that needs judgment — a missing authorization, an eligibility mismatch, a suspected duplicate — pends into the adjudicator queue with the reason attached, so staff work exceptions instead of re-keying the routine. We don’t publish a benchmark auto-adjudication rate; bring your book of business to a walkthrough and watch the adjudication engine run against it.
Plan designs, benefit tiers, and cost-sharing are configured per client group, not shared across your book. A change to one group’s benefit design never touches another’s — the same platform administers a self-funded medical plan and a fully-insured plan side by side, on the same login your team already uses.
Inbound 834 enrollment feeds keep eligibility current for every client group, with effective dating and retroactive terminations handled automatically instead of by hand. A member added mid-month, or termed the week before, resolves correctly against the plan without a manual correction to accumulators or claims history.
Native X12 — 837 claim intake, 835 remittance generation — with clearinghouse connectivity built into the platform for every client group you administer. That’s infrastructure most vendors sell as a separate module or a middleware contract; here it’s included from day one and shared across your whole book.
Check and ACH disbursement runs, EOB generation, and remittance advice for every provider you pay, on the same schedule and controls whether that provider serves one client group or a dozen. Payment history and 1099 tracking stay tied to the provider across your entire book of business, not reset client by client.
Members and providers see claim status, benefit lookups, and their own documents through a portal scoped to their client group — never another client’s data. Branding can vary by client while the underlying system, and your support burden, stays one platform instead of a portal per client.
Capitated arrangements run alongside fee-for-service claims on the same platform, so a client group with a capitation deal for primary care and fee-for-service for everything else doesn’t need a separate system to reconcile the two. Capitation payments and fee-for-service claims post to the same client ledger and the same reporting.
Referral tracking and prior-authorization requirements enforce automatically at the point of adjudication — a claim that needed an authorization it doesn’t have pends instead of paying. Requirements are configured per client group, so one client’s tight authorization rules don’t apply to another client’s open-access plan design.
Pend reasons, aging queues, and threshold notifications route to the right staff automatically, so a claim that’s been sitting for days surfaces instead of aging silently in a shared inbox. Alerts scope to client group and to the adjudicator responsible for working it, across every client on your book.
Per-client reporting for the group that wants its own numbers, and book-wide reporting for your own operation, come from the same underlying data — with each client’s figures kept segregated from every other client’s. No exporting from six systems to assemble one board deck.
Most claims platforms are built to run a single health plan well. A TPA runs dozens, each with its own plan designs, fee schedules, provider networks, and reporting requirements — and that changes what the software underneath needs to do.
Claimaro administers every client group on one platform, the same one behind our self-funded health plan software. Each client carries its own benefit plans, fee schedules, and provider network, configured independently of every other client you serve. Member and claims data segregate between clients at the data layer, not just in the interface — one client group never sees another’s numbers, and neither do you unless you’re looking at consolidated, book-wide reporting.
Adding a client is a configuration exercise, not a new instance or a new contract. Your team builds the plan, maps the fee schedule, and the client goes live on the same platform your other clients already run on — no parallel environment to stand up, no second bill to manage.
Reporting works the same way in reverse: pull a single client’s numbers for their broker meeting, or roll every client into one view of your book. Same data, same platform, two audiences.
| Feature | Claimaro | Typical per-claim platform |
|---|---|---|
| Pricing model | Flat monthly + PMPM | Per claim processed |
| Per-claim fees | None | Yes — scales with volume |
| Starting price | $3,500/mo + $5 PMPM | Quote only |
| Setup | $15,000, published | Quote only |
| Published pricing | Yes | No |
Platform cost that rises with claim volume penalizes exactly the growth a TPA is trying to achieve.
TPA software is the core administrative platform a third-party administrator runs its client health plans on. It handles enrollment and eligibility, claims intake over X12 EDI, adjudication against each client’s plan design, provider payments, and member and provider portals. The distinguishing requirement versus single-plan software is multi-client architecture: one platform administering many client groups, each with its own plan designs, fee schedules, and reporting, with data segregated between them.
Software. Claimaro does not administer plans or compete with our customers for their business — we build the platform TPAs run on. That distinction matters when you are evaluating vendors, because some platforms in this market are owned by organizations that also sell administration services.
Yes — that is the core of the design. Each client group carries its own plan designs, benefit rules, fee schedules, provider networks, and reporting, with member and claims data segregated between clients. Adding a client does not require a new instance or a new contract.
Yes, natively — 837 claim intake, 835 remittance generation, and 834 enrollment, with clearinghouse connectivity built into the platform rather than sold as a separate module or a middleware contract.
Claimaro is published, flat pricing: from $3,500/month + $5 PMPM with a $15,000 setup, and zero per-claim fees. Most of this market prices per claim processed, which means your platform cost rises with the claim volume you take on — the opposite of how a TPA’s economics should work as it grows.
Claims history, member and group records, plan configurations, and accumulator balances migrate together, so in-progress deductibles and out-of-pocket totals carry over rather than resetting mid-year. Migration timing is usually driven by plan-year boundaries rather than by the software.
Twenty minutes, your client roster, live in the product. Or read the seven systems it takes to run a TPA, see what TPA software actually costs, or compare Claimaro to PLEXIS.