Case Study of Third Party Administration (TPA):

81% of Provider Calls for Claims, Eligibility, and Benefits are Processed Without Human Intervention

EHVA 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 provide services 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.

81%

Reduction in calls.

16,471

Covered lives

13,500

Monthly calls processed

24/7

Call handling

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 clientele not just from cost, but because of the physical limitations of the existing call center (square footage, staffing, IT, management, etc.) 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
  • Includes after-hours calls in the evaluated sample
  • EHVA operating full-time in production

When accounting for scope classification, EHVA autonomously resolved approximately 71% of all inbound calls with the possibility of exceeding 80% of total gross calls if it’s decided to move member calls into scope.

Compliance & Data Handling

EHVA 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
  • SOC2 datacenter compliance

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

Conclusion

This deployment demonstrates EHVA’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.

Listen to Claims, Eligibility, and Benefits calls:

Listen to Claims, Eligibility, and Benefits calls:

Listen TO ash

Claims Status Inquiry

Provides real-time claim status updates without transferring to a representative.

PII/PHI Redacted

Listen TO aiden

Provider Eligibility Verification

Verifies member eligibility and benefits instantly by accessing the TPA database in real-time.

PII/PHI Redacted

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"Working with EHVA has been transformative — innovative solutions and visionary thinking have carried us to new levels of success." — Tyler Reeves, Chief Operating Officer at Acuity Group.
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