Claims management and third-party administration
Claims decisions are medical decisions with a payment attached. We handle them the way that implies: clinically validated, fully documented, and defensible if they are ever questioned.
What we do
Claims handling and adjudication
Medical validation across the claims lifecycle, from first notification through to settlement, with clinical sign-off on the decisions that need it.
Pre-authorisation and eligibility
Structured pre-authorisation against policy terms and clinical indication, so exposure is understood and scoped before treatment starts rather than after it.
Third-party administration
Full TPA capability: intake, adjudication, provider liaison, settlement and reporting, delivered under your brand and your service standards.
The assistance arm, run for you
For insurers without an in-house assistance function, we operate as yours, 24/7, clinically led and answering to your escalation policy.
Member and provider communication
WhatsApp, email and telephone all land against the case automatically, timestamped and visible to the whole team, so nobody has to re-tell their story.
Reporting and audit
Case-level reporting with a complete audit trail of who decided what, when, and on what clinical basis.
The claim is downstream of a medical decision
Every medical claim is the financial expression of a clinical event. Someone decided to admit, to operate, to scan, to keep a patient in for another night. The claim simply prices that decision and asks whether the policy responds to it.
Most claims operations are built around the second half of that sentence. Policy terms, diagnosis codes, exclusions, benefit limits: the administrative apparatus for deciding whether a cost is payable. That apparatus is necessary, and it is not sufficient, because it takes the clinical decision as a given. If the treatment was not clinically indicated, or was delivered at the wrong level of care, no amount of policy analysis will surface it.
We handle claims the other way round. The clinical question comes first: was this appropriate, was it necessary, was it delivered in the right setting. The policy question is then applied to a decision that has already been medically validated.
What clinical validation looks like in practice
A UK clinician owns each case that requires clinical input and is accountable for its decisions. In a live claim that means reading the treating team’s plan against the presenting condition, requesting the clinical detail that is missing rather than deciding without it, and engaging the treating physician directly where the two do not reconcile.
That conversation is only possible between clinicians. A handler asking a consultant to justify a length of stay is an administrative obstacle. A clinician asking the same question is a peer, and gets an answer with clinical content in it.
The consequence for the insurer is that decisions hold. A claim declined or reduced on a documented clinical basis survives complaint, appeal and regulatory scrutiny in a way that one declined on a coding technicality often does not.
Pre-authorisation is where the ambiguity goes to die
Disputed claims are usually the residue of an unscoped authorisation. Treatment proceeds under a general assurance of cover, scope expands, and the disagreement surfaces when the invoice does. By that point the member is already treated, the provider is already owed, and the insurer’s position is weak.
Structured pre-authorisation removes most of that. Cover is confirmed against a specific clinical indication and a specific proposed pathway, with scope defined and any extension requiring a fresh decision. It is a marginally slower process at the front end and a dramatically cheaper one at the back.
For more on capturing clinical signal before the claim exists, see Pre-claim clinical intelligence.
Full third-party administration
For insurers who want the function delivered rather than supported, we operate as the administrator: intake, triage, clinical validation, provider liaison, settlement and reporting, all under your brand and to your service standards.
The commercial point worth stating plainly is that we are a dedicated assistance partner and nothing else. We do not underwrite, we do not distribute, and we do not market to your members. When we answer the phone in your name, we are not building a relationship we intend to keep.
Everything on the case, automatically
When someone is unwell far from home they reach out however they can: a WhatsApp message at 3am, an email to whoever last replied, a phone call from a relative in a different timezone. In most operations those land in three separate places and one of them gets lost.
In Atlas, they land on the case. WhatsApp messaging with the insured person, emails routed directly onto the case rather than into a shared inbox, calls, notes and documents in one continuous timeline. Nothing sits in someone’s personal inbox, and no member has to explain their situation twice.
Escalation with defined times
Not every claim can wait for the next working day. When a case is escalated, Atlas routes it by priority and puts it in front of the right person, against commitments rather than aspirations: a senior clinician reviews clinical escalations within fifteen minutes, operational escalations are actioned within thirty, and an executive on-call leader is on the case within thirty minutes where the situation warrants it.
Visibility, not reports
Your team gets its own view. The Atlas client portal shows the live caseload, spend tracked against approved pre-authorisations, and cases awaiting your approval, with every access and every action logged and auditable. Reporting exists, but the operational picture does not wait for it.
For the broader argument about clinical leadership in assistance, see Clinically led, not clinically staffed.
Your team sees the same case we do
The Atlas client portal gives your claims and operations teams a live view of the book, not a monthly report on what already happened.
- Every active case, with status and location
- Spend tracked against approved pre-authorisations
- Cases awaiting your approval, surfaced in one place
- Every access and every action logged and audited
Common questions
What does a clinically-led claims process actually change?
It changes who makes the decision that matters. In a document-led process, a non-clinical handler applies policy wording to a diagnosis code. In a clinically-led one, a clinician reads the clinical picture, determines whether the proposed treatment is indicated, and then the policy question is applied to a decision that is already medically sound. The second is far harder to overturn on appeal.
Can you administer claims under our brand?
Yes. As a third-party administrator we work in your name, to your service standards and your escalation policy. We are a dedicated assistance partner, not an insurer or intermediary. We never sell to your members and never compete for your customer, so the relationship stays yours.
Do you handle pre-authorisation as well as post-treatment claims?
Both, though pre-authorisation is where the value concentrates. Authorising with defined scope establishes what is covered before treatment begins, which removes most of the ambiguity that produces disputed claims later.
How do you handle a disputed or complex claim?
It escalates. A case flagged for clinical escalation is reviewed by a senior clinician within fifteen minutes; operational escalations are picked up within thirty. Complex, high-value or contentious claims get a named clinical lead who owns the decision through to resolution.
What visibility do we get while a claim is live?
Real-time. The Atlas client portal gives your team a live view of active cases, spend tracked against approved pre-authorisations, and anything awaiting your approval, with every access and action logged.
Can you integrate with our existing claims system?
In most cases yes, though talk to us about the specifics. Where direct integration is not practical, the client portal and structured reporting give your team the same operational visibility without one.
Related insights
Second opinions as a cost containment lever
A structured second clinical opinion is filed as a member benefit and behaves like a cost containment tool. Where the treatment plan actually changes, when it is worth commissioning one, and how to run it so it holds up.
Hospitalised abroad: who actually pays, and when
A member is admitted overseas and the clinical picture is only half the problem. Here is how a foreign hospital bill actually gets settled, and why the guarantee of payment decides more of the case than anything that follows it.
What a medical repatriation actually costs, bed to bed
Published repatriation prices are the price of an aircraft. These are the price of getting somebody home: escort, stretcher, air ambulance and road, all in, with what actually moves the number.
Have a case to discuss?
Talk to our clinical and operational teams about a live case, a caseload, or a partnership.