An a la carte network services platform for health plans.
A productized way for a health plan to lease its provider network and offer modular services (portal, payments, call center, core admin) to downstream customers, without rebuilding the operations behind it. This page walks through the architecture, the onboarding flow, the EDI file plumbing, the contact center, and the operating dashboards.
Health Plan (HP)Customer (network lessee)Service Provider (SP)
What this solution does
Turns a network leasing relationship into a packaged, scalable offering with shared plumbing across customers, predictable unit economics, and a single operations team supporting all of them.
$0.25
per claim payment fee
50 / 100
BPS on ACH / Virtual Card
7 mo
implementation, May to Dec 2026
Jan 1 2027
go live
The shape of the offering
One platform, three roles, modular services.
The Health Plan owns the network and the regulatory relationships. The Customer rents access to that network and processes its own claims. The Service Provider runs the operational layer that makes the relationship work day to day.
Health Plan
Owns the network. Sells access.
Holds provider contracts, sets reimbursement, prices claims, and earns BPS revenue on payment volume routed through the platform. Sees a portfolio view across all of its Customers.
Customer
Rents the network. Adjudicates claims.
Receives priced 837s from the HP, runs adjudication on its side, returns 835 payment files, and funds claim payment from its own bank account. Picks the modules it wants: portal, payments, call center, core admin.
Service Provider
Runs the platform. One team, many tenants.
A single operations layer covering everything the HP would otherwise stand up itself:
Onboarding
Receives and processes EDI transactions
Payment execution
Configures and deploys portals (member, provider, customer)
CRM
Contact center
Reporting and analytics
Modular services
Customers pick from Portal, Payments, Contact Center, Core Admin, and a la carte add-ons. Each module shares the same identity, ticketing, and reporting backbone.
EDI native
834 enrollment, 835 payments, 837 claims, plus a benefits flat file. Companion guides published, validations baked in, retries and reconciliation automated.
Routed contact center
Each Customer gets a dedicated 800 number on AWS Connect. Calls hit a screen pop that shows member, provider, and claim context, then route tickets to the right party.
Two reporting lenses
Customers see operational stats. The HP sees those plus its BPS revenue, payment mix, and per-Customer profitability. The platform team sees everything.
Portal preview
A high-level look at the branded self-service portal the SP configures and deploys for each tenant. The same shell is used for member, provider, and customer audiences with role-aware content.
portal.democustomer.com / member
Demo Customer Co.
Dashboard
My claims
Benefits
Find a provider
Documents
Contact us
Welcome back
Maria Chen
PPO Plus 2027
Deductible
$420 / $1,500
Out of pocket
$680 / $4,000
Open claims
2
Recent claim activity
CLM-78412 Family Care Group, $1,284 (in review). CLM-78298 Crescent Imaging, $312 (paid). CLM-78114 Lakeside Hospital, $4,012 (paid).
A static mockup. The same shell renders different navigation and data for member, provider, and customer roles.
Ecosystem architecture
How the pieces fit together.
Hover or click any system to see what it does. Hover or click any integration line to see what flows across it and which direction. Color tells you who owns the system.
Health Plan systemsCustomer systemsService Provider systemsActive selection
Click anything in the diagram to learn more.
Each system is owned by one of the three roles. Each integration carries a specific kind of data, in a specific direction, on a specific cadence. Click around to see who does what.
A focused view of one electronic file flow at a time. Click a tab to switch flows. Animation shows direction.
How to read this view. Five distinct colors, five distinct file types. Inbound flows (834, Benefits, 835 inbound) travel up from the Customer through the HP EDI Gateway and into the SP EDI Hub. The 837 claims flow leaves HP Pricing as a parallel fan-out: one copy goes straight down to the SP EDI Hub, the other crosses sideways to the Customer Adjudication. The 835 round trip is shown twice in pink: solid for the inbound from Customer (initial outcome), short-dashed for the final reconciled 835 returning from SP back to Customer. The green ACH or Virtual Card line is the actual provider payment leaving the SP Payments Engine.
Onboarding
The form that turns a contract into a live tenant.
The Health Plan sends each Customer a personalized link. The contract auto-populates the selected services. The Customer fills in banking, ops contacts, and uploads its bank letter. DocuSign captures the signature. On submit, we create the tenant and queue the file interfaces. Walk through it below.
1 Review contract
2 Confirm services
3 Banking and ops
4 DocuSign and submit
Your contract is ready for review.
This is the master services agreement between the Health Plan and your organization. The selected services on the next step are pulled directly from this contract, so update it here if anything is wrong before signing.
Services elected per Schedule A: Member and Provider Portal, Payments (ACH and Virtual Card), Contact Center, Core Admin Management, Eligibility Loads, Reporting Suite.
Confirm your service selections.
These came from your contract. Add or remove anything you'd like before we provision.
Banking, contacts, and operations.
This is what we need to fund payments, route operational tickets, and provision your file interfaces.
Sign and submit.
Review what you've entered, sign the agreement through DocuSign, then submit. Your tenant provisions automatically and your account manager will reach out within two business days.
DS
DocuSign envelope ready for signature
Sign here to capture the master services agreement and your service selections. Sent to your authorized signer on submit.
✓
Signed by Amanda Demo, CFO
Envelope ID DS-2026-04812 captured. You can now submit.
What happens next, in order:
Tenant provisions in CRM, Contact Center, and Payments Engine
Dedicated 800 number assigned and SIP routes configured in AWS Connect
Companion guides for 834, 835, 837, and the benefits flat file delivered
Account manager schedules kickoff within two business days
Step 1 of 4
✓
Congratulations and welcome aboard
We are so excited to work with you.
Your account manager will be in contact within two business days to finalize onboarding, walk through companion guides, and schedule your joint kickoff. In the meantime, your tenant is provisioning in the background and your dedicated 800 number is being assigned.
Confirmation reference: TKT-2026-04812 · Sent to your operations and finance contacts on file.
File flows
The four file types that keep the platform alive.
Click a tab to walk through how each file moves between Customer, Service Provider, and Health Plan, and what happens at every hop. The Service Provider is the spine: every file enters or leaves through the SP EDI Hub.
Benefits flat file
A pipe-delimited file the Customer publishes that defines its plans, copays, deductibles, and exclusions. The HP uses it to price claims correctly and the SP uses it to render member-facing benefit summaries.
Cadence:Annually or on plan changeDirection:Customer to HP to SPSLA:HP forwards in 1 day, SP loads in 2 daysView companion guide
Reconciliation:Monthly reporting shows how many benefits files we received from each Customer and the date of the last file. Any Customer with no benefits file in the last 13 months is flagged for outreach so we can confirm whether plans actually changed and we missed the file, or plans truly did not change.
Contact center
Routing, screen pops, and four real call patterns.
Each Customer has a dedicated 800 number on AWS Connect. The number is what tells us which tenant the call belongs to before the agent says hello. The screen pop pulls the right context. The agent dispositions the call and the ticket routes to whoever can actually solve it.
Routing logic
Inbound DID identifies the tenant. AWS Connect IVR collects member ID or provider NPI. We authenticate the caller against the CRM, attach the most recent claim and benefit context, and pop the agent's screen with everything in one place. Agents disposition into one of four buckets.
Anything regulatory, member safety, or media-sensitive
AD
Agent Desktop
Live call · 00:42
Demo Customer Co.TKT-2026-04812
Caller
NameMaria Chen
Member IDDC-00845231
PlanPPO Plus 2027
AuthenticatedDOB + ZIP
Most recent claim
Claim #CLM-78412
ProviderFamily Care Group
StatusDenied · no auth
Charged$1,284.00
Suggested action
Auth on file in HP system. Likely processed before adjudication update propagated. Open ticket to Customer Adjudication for reprocessing. Open ticketAdd note
Mock screen showing the agent's view at call answer.
Sample scripts
Pick one to see how the agent guides the call and where the ticket lands.
Dashboards
Three audiences. Three views. Same source of truth.
The Health Plan sees portfolio economics including BPS revenue. The Customer sees its own operational and payment statistics, but never the BPS line. Operations sees everything plus contact center performance. Toggle between them.
Claims paid (Apr 2026 MTD)
184,372
+8.2% vs prior month
$ paid through platform
$42.6M
+11.1%
BPS revenue (HP only)
$266,000
+13.4%
Est. monthly fee for payments
$46,093
$0.25 × 184,372 claims
Claims paid by Customer and provider type
Customer
Primary care
Specialist
Hospital
Ancillary
Total $
Demo Customer Co.
12,840
9,212
3,118
7,994
$14.2M
Northstar Benefits
10,442
7,883
2,401
6,512
$11.8M
Atlas Health Group
8,120
6,201
1,902
5,238
$9.4M
Beacon Care Plans
5,711
4,012
1,108
3,204
$7.2M
BPS revenue by payment type (HP only)
ACH (50 BPS)
$160,000
Virtual Card (100 BPS)
$106,000
Virtual Card carries higher BPS and is encouraged where the provider accepts it. ACH is the default for high-volume institutional providers.
Turnaround and ticket health (across all Customers)
Files received TAT
2.1 days
avg HP receive to SP load
Payments TAT
0.8 days
835 reconcile to provider funded
Tickets closed TAT
1.4 days
opened to closed
Open tickets
412
oldest is 12 days
Viewing as: Demo Customer Co.
Your claims paid (MTD)
33,164
+6.7%
$ paid to providers
$14.2M
+9.0%
Avg claim turnaround
3.1 days
-0.4 days
Exception rate
1.6%
+0.2 pp
Claim reconciliation (this month)
33,518
837s sent to you (priced claims)
33,164
835s received back from you
354
Open: no 835 received yet
Open by age. Click any bucket to see the underlying claims.
Your payment mix
ACH
23,546 pmts
Virtual Card
9,618 pmts
Note: BPS revenue is between the Health Plan and the platform and is not part of your statement.
Top providers paid this month
Provider
Type
Claims
Paid $
Method
Family Care Group
Primary care
1,212
$418,720
ACH
Lakeside Hospital
Hospital
418
$1,920,400
ACH
Crescent Imaging
Ancillary
980
$240,510
Virtual Card
Summit Cardiology
Specialist
612
$385,210
Virtual Card
Your turnaround and ticket health
Files received TAT
2.0 days
your enrollment and benefits load
Payments TAT
0.7 days
your reconcile to provider funded
Tickets closed TAT
1.2 days
tickets routed to your team
Open tickets
28
oldest is 6 days
Calls handled (MTD)
8,914
+4.1%
Avg handle time
4:42
-12s
First-contact resolution
73%
+2 pp
CSAT
4.6 / 5
+0.1
Turnaround and ticket health (across all tenants)
Files received TAT
2.1 days
avg HP receive to SP load
Payments TAT
0.8 days
835 reconcile to provider funded
Tickets closed TAT
1.4 days
opened to closed, all tenants
Open tickets
412
oldest is 12 days
Call volume by Customer
Demo Customer Co.
3,118 calls
Northstar Benefits
2,544 calls
Atlas Health Group
1,910 calls
Beacon Care Plans
1,342 calls
Open ticket aging by tenant
Tenant
Open
0 to 3 days
4 to 7 days
8+ days
Oldest
Demo Customer Co.
28
22
5
1
6 days
Northstar Benefits
19
16
3
0
4 days
Atlas Health Group
14
10
3
1
9 days
Beacon Care Plans
12
8
2
2
12 days
Implementation timeline
From kickoff to live in seven months.
Hover or click any bar to see what's in that workstream. May 2026 kickoff. December 2026 readiness review. January 1, 2027 go-live with hypercare for the first 60 days.
Workstream
May 26
Jun 26
Jul 26
Aug 26
Sep 26
Oct 26
Nov 26
Dec 26
Jan 27
Discovery and contracting
Discovery, scope, contract close
Tenant provisioning
CRM, AWS Connect, Payments tenant
EDI build (834 / 837 / 835)
Companion guides, mapping, end-to-end
Benefits and plan loads
Flat file, plans, fee schedules
Payments setup
Bank, ACH origination, Virtual Card
Contact center setup
DID, IVR, screen pop, training
UAT and parallel runs
UAT cycles 1 to 3, parallel files
Readiness and cutover
Go-live Jan 1, 2027
Hypercare
60 days hypercare
Click a bar to see workstream detail.
Each bar is owned by one of the three roles. The color tells you who is on point. Most workstreams have shared inputs from the other two roles even when one owns them.
Resources
Companion guides and templates.
These would be delivered to every Customer at the end of onboarding. Click a card to preview a layout sample. In a live system, signed PDFs and structured payloads live in the Document Vault and are versioned per tenant.
834
834 enrollment companion guide
How the Customer publishes member eligibility. Full file weekly, change file mid-week.
837
837 claims companion guide
How the HP delivers priced claims to the Customer. Daily.
835
835 payment companion guide
How the Customer returns adjudication outcomes. Daily, reconciled before payment.
FF
Benefits flat file layout
Pipe-delimited file capturing plans, copays, deductibles, and exclusions.
FRM
Onboarding form template
The web form preview from the Onboarding section, with field-level definitions.