Start with the calls that are lookups
Most provider calls to a TPA ask one of three things: is this member eligible, what are their benefits, and where is this claim. Each answer already exists in your admin platform, plan documents, or EOBs. A person on the phone is doing a lookup and reading it back. Those are the calls to take off your team first.
What the results look like
- Acuity Group (16,471 covered lives, about 13,500 calls a month): 81% of in-scope calls were handled autonomously in the first formal production assessment, with a 19% escalation rate. Counting every inbound call, including out-of-scope member calls, about 71% were resolved without staff. Read the case study.
- CareFactor (30,000 covered lives, about 200 calls a day): 90% autonomy. Benefits questions are answered from each plan summary and SPD; claims questions from the claim status, the EOB, and more. Read the case study.
Both TPAs report the same outcome: the call center stops being buried in routine provider calls and can focus on members and on the calls that need judgment.
The order to do it in
- Pick one call type. Claims status or eligibility is the usual first line. Most clients start with one and add more once the reporting proves out.
- Connect the data. The agent reads your admin or adjudication platform through its API, a secure data feed, or a scheduled extract, and plan documents for benefits questions.
- Set scope and escalation rules. Decide what is in scope and what must go to a person. Acuity excluded member services and prior authorizations by design; CareFactor transfers PBM and prior authorization questions to the right outsourced vendor for each group.
- Keep your numbers. The agent can sit behind your existing numbers and IVR, take overflow only, or run a dedicated line.
- Run it around the clock. Urgent care centers calling on a weekend get eligibility answers then, not on Monday.
- Measure resolution, then expand. Review every call, not a sample, and add call types once the first one is steady.
Typical time from kickoff to live calls is about five days for a single call type on a platform with a modern API. A full provider and member line across many plan designs takes longer, and you find out which you are in during discovery.