Providers throughout the United States cannot sustainably treat injured workers without reliable, up-to-date billing information for insurers and self-insured employers.

To receive payment, providers must know the Third-Party Administrators (TPAs) and clearinghouses insurers and self-insured employers use to manage the bills providers send to them.

Insurers and employers can (and often do) change TPAs and clearinghouses, making workers’ comp billing even more challenging for practices’ administrative staff. daisyBill is here to help—whether or not your practice uses daisyBill.

Today, we debut the first of our periodic roundups of TPA and clearinghouse changes. Knowing where (and how) to send your bills is an essential step to correct, quick reimbursement. We aim to fill the workers’ comp information void by supplying free billing updates, data, and insights to help the providers who heal injured workers.

Together, we’re stronger.

Claims Administrators and TPAs Defined: Roles & Responsibilities

All employers are legally responsible for paying for the cost of treating their employees’ work-related injuries. Employers can meet this financial obligation by either:

• Obtaining workers’ comp insurance, or
• Self-insuring

While the insurer or the self-insured employer is financially responsible for an injured worker’s claim, these entities often do not manage a.k.a. “administer,” the details of injured workers’ claims. To manage the many claim details, including payment of medical bills, insurers and self-insured employers must either:

• Engage a “Third Party” claims administrator—known as a TPA—to administer workers’ comp claims, or
• Self-administer their workers’ comp claims

To receive payment for treating injured workers, providers must send their bills to the insurer or self-insured employer’s claims administrator. 

Clearinghouses Defined: Roles & Responsibilities

Almost every claims administrator—whether an insurer, TPA, or self-insured self-administered employer—lacks the technology to accept and compliantly respond to bills providers send electronically, as e-bills. To manage e-bills, claims administrators hire a clearinghouse vendor to:

• Accept providers’ e-bills on behalf of the claims administrator
• Return electronic acknowledgments to providers, documenting receipt of e-bills and indicating if the e-bill was accepted for payment
• Send Explanations of Reviews electronically (e-EOR) to providers, which automatically post all the payment details to the provider’s billing system

Generally, providers should send their e-bills directly to the clearinghouse vendor hired by the claims administrator. However, CorVel (a TPA) and the federal Department of Labor (DOL) do not use a clearinghouse vendor, so providers can directly send these entities their e-bills.

daisyBill Wants to Help

The bottom line is that knowing and keeping track of TPAs and clearinghouses is the key to successful bill delivery and payment.

It’s also a full-time job!

That’s why daisyBill has spent the last decade-plus constructing a complete database of claims administrators, including TPAs, insurers, and self-administered self-insured employers, as well as the networks of their clearinghouse vendors.

To empower all practices navigating the ins and outs of getting workers’ comp bills paid, we are sharing the claims administrator and clearinghouse information we maintain for our clients. Below are the latest changes in TPAs and clearinghouses for July 2024.

Employers’ Claims Administrator Updates

As of the effective date(s) listed below, the self-insured employer listed no longer uses the ‘Prior Claims Administrator’ and instead uses the ‘Current Claims Administrator.’

The ‘Current Claims Administrator’ is responsible for managing payment of the employer’s workers’ comp bills as of the effective date listed. For e-billing purposes, the table also lists the clearinghouse the claims administrator utilizes.

*The San Diego Unified School District now self-administers its own workers’ comp claims effective 7/1/2024.

Clearinghouse Updates

As of the effective date(s) listed below, providers must submit bills to the claims administrator listed using the ‘New Clearinghouse’ and the Payer ID assigned to the claims administrator by the New Clearinghouse.

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