Starting the Conversation: why now?

• Tell me about your current decision to consider self-funding, what prompted it and when this conversation began.
• How many employees are in the benefits population you expect to self-fund? Options: Under 1,000, 1,000 to 2,499, 2,500 to 9,999, 10,000 to 25,000
• When was the last time your team ran a multi-year model comparing fully insured versus self-funded costs? Options: Within 3 months, 3 to 12 months, More than 12 months, Never
• Who on your team will be most accountable for month-to-month funding decisions and cash flow forecasts? Options: CFO/Controller, Head of Benefits/Total Rewards, Treasury/FP&A, Benefits Consultant, Other
• Which stakeholders must sign off on a change to administration or stop-loss, and which are most likely to slow a decision? Options: Finance, Benefits leadership, Legal/compliance, Board or owner, Broker/Consultant, Other
• How quickly does your finance team need final pricing and a SOW to include this change in the next budgeting cycle? Options: Within 2 weeks, Within 4 weeks, Within 8 weeks, Next quarter, Not on a fixed budget timeline

Funding reality and appetite for risk

• If a single high-dollar claim or a two-month run of high claims caused your cash balance to drop below your tolerance, what would that do to your ability to operate or meet payroll obligations?
• Describe the worst month in the last two years for claims volatility, including the funding swing and how you covered it.
• Which of these funding arrangements do you currently use or plan to use? Options: Monthly pay-as-you-go funding, Levelized funding with annual true-up, Partial prefunding, Internal captive for high-cost claims, Other
• How many months of claims reserve do you target as a minimum cash buffer? Options: None, 1 month, 2 months, 3 months, More than 3 months
• Who would authorize an emergency capital contribution or short-term loan if claims exceed budget unexpectedly? Options: CFO, CEO/Owner, Board, Treasury/Finance lead, Other

Where claims operations hurt the most

• Walk me through the most frustrating experience you have had with claims turnaround or access to claims data, and who felt the pressure first.
• Which claims feeds and file formats do you currently receive from your administrator or carriers? Options: 837 professional/Institutional (EDI), 835 Remittance (EDI), CSV or flat files, API-based extracts, None/Irregular files
• When provider payment timing slips, which downstream reporting or vendor payments break first? Options: Provider reconciliations, Pharmacy vendor settlements, Stop-loss recoveries, Member reimbursements, Other
• Tell me how your team uses claims analytics today, which dashboards you rely on, and which reports are produced monthly versus ad hoc.
• If your analytics could show the top five drivers of cost within 30 days of month end, what decision would you accelerate that you cannot today?

Design choices that change risk

• How would a missed stop-loss attachment point or an unexpected corridor shortfall change your willingness to remain self-funded?
• Which stop-loss attachment levels and aggregate corridor structures are you currently modeling for renewal? Options: $25k/$50k specific, 125% aggregate, $50k/$100k specific, 125% aggregate, Higher attachment with aggregate corridor, Specific only, Undecided
• Describe any recent stop-loss recoveries or denials that materially affected your cash flow or renewal strategy.
• Who owns the relationship with your benefits consultant, and how involved are they in claims reviews and renewal negotiations? Options: CFO/Finance, Benefits Director, Third-party consultant, Broker only, Other
• If you could make one plan-design change that would meaningfully reduce your tail risk, what would it be and why?

Obstacles that can stop a go-live

• Which regulatory or payroll timing issue has the biggest chance of delaying a transition for you? Options: State filings and registrations, Payroll match timing, ERISA or HSA plan amendments, Stop-loss licensing, Other
• List any current contracts, carve-outs, or stop-loss terms that would prevent a new administrator from taking full claims responsibility immediately.
• Estimate the number of state-level compliance filings or registrations the seller would need to support on your behalf. Options: None, 1 to 5, 6 to 15, More than 15
• If a single integration point, for example claims EDI, payroll, or eligibility, was delayed by more than six weeks, would that stop your planned go-live? Options: Yes, No, It would delay but not stop, Unsure
• Who in legal or compliance must review a stop-loss policy before binding, and what is their typical review timeline?

The other options you are weighing

• Why would you choose to stay with your incumbent administrator instead of switching, and what would need to change to make you switch immediately?
• Which of these alternatives have you actively evaluated or invited to bid? Options: Incumbent administrator renewal, New TPA with integrated stop-loss, Stop-loss carrier admin bundle, Broker-proposed captive, Internal administration build
• If you decided to keep your current approach, what three facts about it would have to be true for you to stay?
• Has anyone on your team proposed solving administration or stop-loss needs internally without an outside partner? Options: Yes, actively pursuing internal solution, Discussed but not resourced, No one has proposed that
• What is the single deal breaker that would make you cancel vendor selection and stay with the incumbent?

Operational readiness and constraints

• If your eligibility or payroll feed cannot be provided in standardized files within 30 days, why would that force a push or cancellation of implementation?
• Which systems must integrate before go-live, and who owns each integration internally? Options: HRIS/eligibility, Payroll, Claims EDI, Benefits enrollment platform, BI/analytics platform, Other
• Give examples of the most common data quality issues in your claims set, with approximate percent of affected records.
• Who will be the named data owner with authority to sign data sharing agreements and approve production extracts? Options: Benefits Director, CFO/Finance lead, IT/Data owner, Third-party consultant, Other
• Rate your internal technical capacity to support integrations, from fully staffed to no dedicated resources. Options: Fully staffed with 2+ engineers, 1 dedicated technical resource, Shared resource across projects, No dedicated resources
• If your internal team could only spare one FTE through implementation, would that be sufficient to proceed on your target timeline? Options: Yes, No, Maybe, with vendor support

How you will know this worked

• If the first 12 months of administration did not achieve your target funding variance, would you consider changing administrators? Options: Yes, No, Depends on reasons
• Which financial metrics must improve to justify a switch, select all that apply? Options: Reduction in year-over-year claims trend, Lower total administrative cost, Reduced cash flow volatility, Higher stop-loss recoveries, Faster claims adjudication times
• How do you quantify acceptable stop-loss performance during the first policy year, for example maximum allowed denials or a minimum recovery rate?
• When the pilot or first-cycle report proves the target, who has authority to sign an expanded contract and how soon could they commit? Options: CFO within 2 weeks, CFO after executive review, Board approval required, Other
• Identify the one timeline or budget constraint that would make your executive team cancel the transition.
• Are there SLA targets or reporting cadence you require to consider the engagement successful? Options: Monthly executive report, Weekly claims exceptions, Daily data feed health checks, 24 hour critical ticket response, Other

Concrete next steps and commitments

• If we met your success criteria in a 90 day pilot, what internal approvals would still be needed before you sign a master services agreement?
• List the names, roles, and best contact method for the three people we should keep tightly involved during discovery and implementation.
• Which documents or sample files can you make available in the next two weeks, for example a month of claims detail, eligibility extract, and your current stop-loss policy? Options: Claims detail file (yes/no), Eligibility extract (yes/no), Current stop-loss policy (yes/no), Other supporting docs (yes/no)
• How soon can your team commit to a technical kickoff once the statement of work is shared? Options: Immediately, 1 to 2 weeks, 3 to 4 weeks, More than a month
• If we deliver a draft SOW next week that matches your requirements, would your team be prepared to sign within 30 days? Options: Yes, Maybe, with minor edits, No

• Plan Experience & Analytics Review

• Confirm the current state and its cost to your team
• You confirm the demonstrated adjudication workflow and timing addresses the delays that cause your cash flow volatility.
• Run a sample claims adjudication on the provided anonymized extract and deliver a timing and funding-impact report before the next review.
• You confirm the analytics outputs provide the funding forecast and vendor-level drill-downs you need for month-to-month decisions.
• Run a claims adjudication walkthrough using your scenario
• Provide an anonymized representative claims extract, the current monthly funding report, and the list of your top 10 providers by spend.
• Validate provider network access and repricing impact
• Confirm the exact reports and KPIs required by finance and benefits for month-end review.
• You agree on the remaining evidence and a timeline to complete a sample claims run and deliver the funding-impact report.
• Show clinical program workflows and outcomes for high-cost cohorts
• Schedule the sample run week and identify internal reviewers who will approve the delivered evidence.
• Prove analytics and reporting against your use cases
• Forced validation
• Agree evidence needs and next steps

• Plan Experience & Analytics Review
• Solution Experience Deck — Plan Experience & Analytics Review
• Plan Experience & Analytics Solution Brief

• meeting
• slides
• document

• Adjudicate and pay medical, dental, and vision claims
• Provide provider network access and claims repricing
• Administer prior authorization and utilization management
• Deliver care and case management for high-cost members
• Issue integrated specific stop-loss coverage
• Manage aggregate stop-loss monitoring and settlement
• Process stop-loss claim reimbursements and recoveries
• Provision claims analytics dashboard with diagnostic drill-downs
• Deliver monthly funding and cash flow reports
• Provide plan design modeling for renewal scenarios
• Prepare ACA reporting and generate 1094/1095 filings
• Support ERISA, HIPAA, and mental health parity compliance

Adjudicate and pay medical, dental, and vision claims

• Confirm which lines of business we will adjudicate for you (medical, dental, vision). Options: Medical, Dental, Vision, All listed
• List expected monthly claim volumes by line and the peak month estimate used for cash forecasting.
• Estimate the average allowed claim size and the expected annual count of claims exceeding $50,000. Options: Less than 5, 5-20, 21-50, More than 50
• Provide the claim submission formats and payer exchange methods you accept (for example EDI 837, paper, other). Options: EDI 837 Institutional/Professional, Paper EOBs, Other electronic format
• State target adjudication service levels for first-pass decisions and time-to-payment (for example payment issued within 5 business days of adjudication). Options: 3 business days, 5 business days, 10 business days, Custom
• Define the acceptance criteria and evidence that will validate accurate claims adjudication and payment (examples: payment accuracy rate, EOB reconciliation, within-SLA payment timing).

Provide provider network access and claims repricing

• Select the network access model you require for repricing and provider access (PPO, narrow network, reference-based, or maintain current contracted network). Options: Standard PPO, Narrow network, Reference-based pricing, Maintain existing contracted network
• List the number of provider contracts, payer/provider IDs, and directories that must be onboarded for repricing reconciliation.
• Indicate the repricing methodology preferred for claims (provider fee schedule, percent-of-billed, allowed-charge table). Options: Provider fee schedule, Percent-of-billed, Allowed-charge table, Custom rule set
• Describe the repricing audit and validation rules you require (for example NPI matching, CPT/ICD-10 validation, bundling/unbundling rules).
• Detail the provider data fields required for reconciliation and checks (for example NPI, Tax ID, contracted rate code, effective date).
• Select the cadence for provider contract refreshes and repricing rule updates. Options: Monthly, Quarterly, Semi-annually, On contract change only

Administer prior authorization and utilization management

• Which service categories should require prior authorization under your plan (for example advanced imaging CPT ranges, inpatient admissions, elective surgeries)? Options: Advanced imaging, Inpatient admissions, Elective surgeries, Infusion therapies, Other
• Who will supply the clinical utilization management criteria you want applied (existing medical policies, your consultant, or co-developed guidelines)? Options: You will provide, Use standard clinical criteria, Co-develop criteria
• Specify the response-time requirements for prior authorization decisions and preferred communication method (electronic prior auth, secure portal, phone). Options: Within 24 hours, 48 hours, 72 hours, Custom
• Provide the exact data elements to capture on authorization requests for auditability (for example member ID, ICD-10, CPT, attending NPI, anticipated length of stay).
• List the reporting fields required to support utilization management audits and appeals (for example auth ID, decision timestamp, clinical reviewer ID, denial reason code).
• Estimate monthly prior authorization request volume by service category for resourcing and SLA planning. Options: Less than 100, 100-500, 500-2,000, More than 2,000

Deliver care and case management for high-cost members

• List the clinical and cost thresholds used to qualify members for case management (for example annual spend > $25,000, two+ hospitalizations in 12 months).
• Specify the desired case manager-to-member ratio and preferred outreach cadence (telephonic monthly, biweekly, in-person when discharged). Options: 1:50, 1:100, 1:200, Custom
• Describe the clinical outcomes and cost metrics you want tracked for case-managed members (for example 30-day readmission rate, medication adherence, total cost-of-care).
• Provide integration requirements for member-level care plans in the claims dashboard (which fields must appear: member ID, enrollment date, care team contact).
• Outline authorization or escalation rules for intensive services managed through case management (for example home health start threshold, DME approvals).
• Estimate the expected annual enrollment into care management and average case duration in months. Options: Less than 50 members, 50-200, 200-500, More than 500

Issue integrated specific stop-loss coverage

• Select the specific stop-loss attachment per covered life you are targeting. Options: $25,000, $50,000, $100,000, Custom amount
• Indicate whether specific stop-loss should attach on an incurred basis, paid basis, or a hybrid approach. Options: Incurred, Paid, Hybrid
• Provide the expected enrollment file cadence and preferred format for stop-loss eligibility (for example monthly CSV with member DOB, coverage dates, plan code). Options: Monthly CSV via SFTP, Real-time API, Ad-hoc file uploads
• Describe the member- and claim-level detail required to adjudicate specific stop-loss claims (for example claim line detail, ICD-10, paid amount, EOBs).
• State the run-in and run-out coverage expectations and how late claims should be handled for stop-loss adjudication. Options: Standard plan year run-in/out, Extended run-out required (specify months), Custom rules
• List the evidence that will validate a successful specific stop-loss bind and initial claim transfer (for example enrollment reconciliation tolerance and first claim reimbursement timeline).

Manage aggregate stop-loss monitoring and settlement

• Select the aggregate attachment method you prefer (example corridor as % of expected claims, fixed-dollar aggregate attachment). Options: Corridor as % of expected claims, Fixed-dollar attachment, Custom method
• List the cadence for aggregate monitoring reports and the key fields required (for example YTD paid, projected run-rate, corridor remaining). Options: Monthly, Quarterly, On request
• Provide your preferred settlement frequency and invoicing method for aggregate settlement activity. Options: Annual settlement, Semi-annual, Quarterly, Monthly reconciliation only
• Specify the financial tolerance threshold that should trigger reconciliation or dispute for aggregate calculations (for example 2% of expected claims). Options: 1%, 2%, 5%, Custom
• Describe the audit artifacts you will require for aggregate settlement (for example monthly paid claim roster, eligibility reconciliation, remittance ledger).
• Estimate expected plan-year paid claims and the projected aggregate attachment amount used for initial pricing.

Process stop-loss claim reimbursements and recoveries

• Provide the preferred submission workflow for stop-loss claim documentation (secure SFTP, portal upload, encrypted email, paper packet). Options: Secure SFTP, Secure portal upload, Encrypted email, Paper
• Detail the mandatory documentation required for each stop-loss reimbursement (for example itemized EOBs, facility invoice, proof of payment).
• Specify target timelines for claim determination and reimbursement measured from complete submission receipt. Options: 15 days, 30 days, 45 days, Custom
• Indicate your subrogation and recovery preferences including use of third-party recovery vendors and assignment-of-benefits handling. Options: We require active subrogation, No subrogation, We will discuss case-by-case
• Describe the reporting fields required per reimbursement transaction (for example claim ID, gross paid, reimbursed amount, recoveries applied).
• Estimate the annual stop-loss claim count and average reimbursement amount to size staffing for adjudication. Options: Less than 10, 10-50, 51-200, More than 200

Provision claims analytics dashboard with diagnostic drill-downs

• Confirm the KPI set and drill paths required on the dashboard (for example total paid by ICD-10, provider specialty, member cohort, monthly trend).
• Specify the maximum acceptable data latency from claim adjudication to dashboard visibility (for example near real-time, daily, 48 hours). Options: Near real-time (<=4 hours), Daily, 48 hours, Custom
• Define the acceptance criteria and evidence for analytics readiness including data completeness thresholds and drill-down availability.
• Provide the cohort filters and default segments to include (for example by plan, location, employee class, age band).
• Specify required export formats and API access for dashboard extracts (for example CSV exports, JSON REST API with token authentication). Options: CSV export, JSON REST API, Both
• Describe desired visualizations and scheduled report deliveries (for example provider heatmap, Pareto by diagnosis, monthly executive PDF).

Deliver monthly funding and cash flow reports

• Select the delivery method and frequency for funding reports (for example monthly PDF via portal, automated SFTP CSV). Options: Monthly PDF via portal, Automated SFTP CSV, Email delivery
• List mandatory fields and line items required on the funding report (for example premium received, paid claims by line, reserves, stop-loss premium).
• Specify whether you require projected cash flow forecasts and the planning horizon (for example 3-month, 6-month, 12-month forecasts). Options: 3 months, 6 months, 12 months, No forecast
• Identify reconciliation fields and the owner responsible for monthly funding report sign-off.
• Estimate the typical monthly cash reserve target and whether minimum balance reporting is required. Options: No minimum, Specify minimum, Custom reporting only

Provide plan design modeling for renewal scenarios

• List the plan design levers you may change at renewal (for example deductible tiers, coinsurance percentages, out-of-pocket maximums, HSA eligibility).
• Specify the modeling outputs required to support renewal decisions (for example PMPM cost, employer budget impact, stop-loss premium change).
• Indicate the modeling timeframe and scenario types you want produced (for example 12-month renewal, 24-month trend, catastrophic shock scenario). Options: 12-month, 24-month, Multi-year
• Provide the member-level inputs needed for modeling (for example enrollment file with age, gender, plan choice, HSA status).
• List the model assumptions you require to be explicit (for example trend rate, medical cost per employee, migration percentages).
• Estimate the number of distinct renewal scenarios you want generated. Options: 1-3, 4-6, 7+

Prepare ACA reporting and generate 1094/1095 filings

• Specify which employer entities will be included in ACA filings and the method used to determine Applicable Large Employer (ALE) status.

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Order Form & Pricing Schedule
• Stop-Loss Insurance Policy
• Service Level Agreement (SLA)
• Data Access and Integration Agreement
• HIPAA Business Associate Addendum (BAA) / Data Processing Agreement (DPA)
• Implementation & Cutover Acceptance

• Go-live Health Check (weeks 1-4)
• First Outcomes Review (weeks 4-10)
• Acceptance Gate Review (around day 90)
• Ongoing Quarterly Success Review

• Update SLA exception logs and produce a corrective action plan for any repeated breaches.
• Restate acceptance criteria and numeric targets
• Produce a documented pass/fail result against each numeric criterion recorded in the Solution Scope.
• If any criteria fail, record a concrete remediation plan with dates for completion and re-evaluation.
• Capture a formal acceptance decision with a named signatory for the buyer where applicable.
• Publish the acceptance decision record, including pass/fail for each criterion and the named signatory.
• Create remediation tasks for any failed criteria with target closure dates and test evidence requirements.
• Schedule the re-evaluation meeting for any failed items on the agreed date.
• Update the Solution Scope status to reflect accepted deliverables and outstanding remediation items.
• Trend review for key financial and operational metrics
• Confirm whether financial and adjudication metrics are trending toward targets and identify any sustained gaps.
• Reduce the count of high-priority open issues and commit dates for resolution.
• Agree a short list of operational actions for the next quarter with target dates.
• Publish the quarterly metrics pack with annotated variance explanations and next-step items.
• Close or reassign any stale enhancement requests and publish the updated backlog prioritization.
• Confirm scheduled dates for interim checkpoints on any high-risk remediation items.
• Re-confirm success criteria and owners
• Confirm production configuration and feeds match the documented deployment checklist.
• Confirm the incumbent system is either decommissioned or retained read-only, with archived data and a closed fallback plan.
• All critical blockers are recorded with target resolution dates.
• Publish the go-live health summary including open blockers and owners for hypercare.
• Perform legacy data archive verification and produce the retention/restore report.
• Enable any missing admin or user accesses identified during the validation checks.
• Schedule a follow-up in two weeks to confirm blocker resolution progress.
• Present first-cycle outcome data
• Agree corrective actions for each metric that is outside tolerance and set target dates for remediation.
• Confirm feed and reporting fixes needed to ensure accuracy for the acceptance gate.
• Establish the timeline and deliverables expected at the acceptance gate.
• Publish the outcome dashboard used in the meeting and annotate any known data-quality limitations.
• Open remediation tickets for root-cause fixes with target resolution dates aligned to the acceptance gate.
• Deliver an updated funding projection reflecting identified variances and expected remediation impact.
• Confirm stop-loss claim submission status for any large claims and document expected recoveries.
• Present outcome data against each criterion
• Open issue and enhancement request burn-down
• Diagnose root causes for variances
• Deployment and migration validation
• Document per-criterion pass or fail and remediation plan
• Early adoption and usage signals
• Operational SLA and reporting delivery review
• Confirm stop-loss activity and recoverables
• Agree next-quarter action plan
• Incumbent wind-down confirmation
• Capture formal acceptance decision
• Validate reporting quality and data feeds
• Blockers and open issues triage
• Agree timeline for remediation closure and re-evaluation
• Agree corrective actions and timeline to acceptance gate
• Agree immediate remediation actions