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TPA Services

Our TPA services provide a complete end to end solution, from billing and collection (including direct to the insured), policy administration, through to claims adjudication and payment. We can provide any of these services on a stand-alone basis.

We have the capability to provide our services in English, French and Spanish. This is part of our commitment to providing exceptional service to all of our clients.

Third Party Administration

Claims Services

Sutton Special Risk has been paying Medical, Dental, Disability, Life and Accidental Death Claims in Canada and USA for over 25 years. Our multilingual professional Claims Adjudicators are fully trained and experienced in all Benefit areas. Our claims adjudication systems have been developed to ensure prompt service, secure data, and useful and timely management reporting. Services include;

  • Timely and accurate Claims Processing of Major Medical and Dental, Life, AD&D, Waiver of Premium, Short Term and Long Term Disability Benefits
  • Prescription Drug Card Service
  • Pro-active Disability Claims Management Services
  • Multilingual forms and correspondence
  • Toll free, multilingual claims inquiry service
  • Medical case management
  • Comprehensive Activity and Cost Control Reports
  • Cost-plus claims administration of uninsured benefits
In addition, our sophisticated US Claim Payment Software gives us the ability to offer the following services;
  • Detailed data tracking, including diagnosis, procedure, provider type, units of time, reasonable and customary charges
  • Auto adjudication
  • Electronic claims reception, processing, and remittance capabilities
  • Compliance with all US Regulatory and Reporting requirements, (COBRA, HIPAA, IRS)
A key component to effective U.S. claims management is cost containment. Our services include;
  • Effective cost containment through access to Preferred Provider Organizations (PPO)
  • Utilization review
  • Centres of Excellence Program
  • Out of Network claims negotiations.
Administration Services

Our dedicated team can provide a full range of administration services to our clients in Canada and the USA, including;
  • Premium Billing, Collection and Remittance
  • Toll free multilingual call centre services
  • Processing of Evidence of Insurability
  • Life Insurance Conversion Assistance
  • Sophisticated enrollment and eligibility tracking tools
  • Comprehensive activity and cost control reporting
  • Compliance with all US regulatory requirements (COBRA, HIPAA, IRS)
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