TPA & claims attribution
What a TPA is
Section titled “What a TPA is”A Third-Party Administrator (TPA) is an entity that performs insurance administration functions — especially claims handling/adjusting — on behalf of an insurer or self-insured plan, without bearing the underwriting risk itself. A TPA processes, investigates, and settles claims for a fee. STABLE
The original Glacis briefing explored claims support as a revenue route. Technical evidence supply and regulated claims adjusting are separate functions; actual authority and compensation require the appropriate legal and contractual basis. GROUNDED · Glacis STABLE
Where it sits relative to the MGA
Section titled “Where it sits relative to the MGA”The MGA, the carrier, and the TPA are distinct roles that can overlap:
An MGA can also hold delegated claims authority — see 04 What is an MGA — in which case the MGA performs a TPA-like function. The licensing/registration to act as a TPA or claims adjuster is separate from the producer license. STABLE
Claims attribution = the Glacis angle
Section titled “Claims attribution = the Glacis angle”When an AI system is alleged to have contributed to a loss, scoped records can help reconstruct decisions and actions. A signed record does not establish the legal cause of a loss, correctness of its assertions, or insurance coverage. Corroborating observations and qualified investigation remain necessary. STABLE
This maps directly onto two things the exam and the regulators care about:
- Unfair claims settlement practices — the body of law governing how claims must be handled (no unreasonable delay, proper investigation, good-faith settlement). See 12 Ethics & trade practices. STABLE
- AI claims litigation — Kisting-Leung v. Cigna (AI denials without proper review) and Kelly v. State Farm (alleged discriminatory claims algorithms) are exactly the disputes attribution evidence speaks to. See 02 AI claims litigation. GROUNDED · Law360
Regulatory review
Section titled “Regulatory review”Documentation and model provenance can be relevant to regulatory review. Establish which artifact answers which question; neither attestation nor a framework mapping establishes compliance by itself. See current AI evaluation work. STABLE
How it ties the three streams together
Section titled “How it ties the three streams together”A scoped packet may be reviewed for underwriting or claims purposes. Each use needs its own acceptance, supporting observations and authorised decision owner. Lower losses, pricing benefits and claims authority do not follow from the existence of the record. STABLE