What Is Claims Transparency?

A claim is a request for payment that is submitted by a health care provider for costs of healthcare services and/or supplies provided to a plan participant by a hospital, doctor, or other health care facility. How does transparency relate to that and why is it important?


Claims transparency refers to information available to employers and plan participants that raises awareness and understanding of what activity is occurring with their claims and health plans. Transparency enables employers and ultimately plan participants to discern information such as price, safety and quality, billing accuracy and more.

State and federal regulations require more tracking and sharing of information now more than ever. Traditional health insurance carriers however, are not obligated to share these insights with clients. As a result, employers aren’t always aware of where their money is being spent or how and when their plan participants are using their benefits. Unfortunately, employers have become used to ‘not knowing’ and having incomplete information. The result is paying higher healthcare costs.

Self-funded health plans on the other hand, facilitated through a third party administrator (TPA) provide accurate, meaningful and usable information to employers on a regular basis.  These insights help employers realize available opportunities to enhance their plan, increase cost savings, or influence and educate their plan participants in achieving and maintaining better health.


Transparency in claims serves us all:


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Plan Participants

Having access to information on a provider’s price, quality of care and overall safety enables personal decisions of choice with confidence and comfort.

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Transparency improves plan strategy through informed decision making. These insights promote better decision making and provide opportunities.

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Healthcare Community

Information available through claims transparency helps nurture a healthy community by driving down costs and promoting high quality standards.


Frequently Asked Questions

Q: What are the benefits of claims transparency?

A: Claims transparency promotes fair pricing, provides plan participants with tools to make better care choices, and allows employers to make data supported decisions. Together these attributes help reduce the total cost of healthcare.

Q: How does working with a TPA optimize the benefits of claims transparency?

A: Unlike traditional models, the transparency that comes from working with a TPA provides employers with greater access to more meaningful data. TPAs are rooted in the belief that transparency is key to effective decision making.

Want to Learn More?

Additional SmartSheet topics are available on the Educational Resources page.




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