81% of TPA provider calls resolved without staff.

Overview

EHVAhealth was deployed to autonomously handle inbound provider calls for a third-party administrator supporting 16,471 covered lives for one of multiple groups, with the goal of alleviating call center load and providing service 24/7. The system was designed to manage eligibility, benefits, and claims inquiries end to end, while intentionally excluding member services and prior authorizations. The deployment achieved 81% autonomy on in-scope calls in its first formal production assessment, with clear paths to further optimization.

The challenge

Provider call volume placed a consistent operational burden on live staff, particularly for repetitive, transactional requests such as eligibility verification and benefits inquiries. This prevented the client from scaling operations and enrolling additional clients, not just because of cost but because of the physical limits of the existing call center: square footage, staffing, IT, and management. The client needed a solution that could:

• Handle provider calls accurately and autonomously using information updated daily
• Maintain strict scope boundaries
• Preserve compliance with healthcare data handling requirements
• Escalate only when necessary

Results

A formal production assessment showed:

• 81% of in-scope calls handled autonomously
• 19% escalation rate on in-scope calls
• After-hours calls included in the evaluated sample
• EHVAhealth operating full time in production

Accounting for scope classification, EHVAhealth autonomously resolved approximately 71% of all inbound calls, with the possibility of exceeding 80% of total gross calls if member calls are moved into scope.

Compliance and data handling

EHVAhealth was deployed with healthcare compliance requirements in mind, including:

• HIPAA-aligned handling of PHI
• Controlled access to eligibility, benefits, and claims data
• Intentional scope restrictions to reduce risk exposure
• Full call logging and auditability
• SOC 2 datacenter compliance

No member services or prior authorization workflows were included in scope, by design.

Conclusion

This deployment demonstrates EHVAhealth's ability to operate reliably within a regulated third-party administration environment, handling high-volume provider calls with minimal human intervention while maintaining operational control and compliance.