INSURANCE THIRD-PARTY ADMINISTRATOR (TPA) OVERSIGHT CHECKLIST 2026

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--- CONTRACTUAL COMPLIANCE & SLA MONITORING ---
[ ] Contract Renewal Date
[ ] Current SLA Status (Meeting All SLAs, Minor Breach Identified, Critical SLA Violation)
[ ] Total Number of Identified SLA Breaches
[ ] Monitored SLA Metrics (Claim Acknowledgment Time, Adjudication Turnaround Time, Payment Accuracy Rate, Document Turnaround Time)
[ ] Description of Recent SLA Non-Compliance
[ ] Quarterly Compliance Report Documentation
[ ] Compliance Officer Verification

--- CLAIMS PROCESSING & ACCURACY AUDIT ---
[ ] Claim Review Date
[ ] Claim Adjudication Status (Approved, Denied, Pending Investigation, Closed)
[ ] Disbursed Amount ($)
[ ] Error Types Identified (Incorrect Deductible Applied, Missing Supporting Documentation, Incorrect Claimant Information, Processing Delay, Calculation Error)
[ ] Detailed Discrepancy Notes
[ ] Supporting Evidence/Audit Logs
[ ] Auditor Verification

--- DATA SECURITY & PRIVACY GOVERNANCE ---
[ ] Last Security Audit Date
[ ] Data Encryption Standard in Use (AES-256, TLS 1.3, Other)
[ ] Compliance Certifications Held (SOC2 Type II, ISO/IEC 27001, GDPR Compliant, HIPAA Compliant)
[ ] Data Breach Incident History Summary
[ ] Upload TPA Data Privacy Policy
[ ] Compliance Officer Verification

--- FINANCIAL OVERSIGHT & PREMIUM MANAGEMENT ---
[ ] Audit Period Start Date
[ ] Audit Period End Date
[ ] Total Premium Volume Audited
[ ] Premium Reconciliation Status (Fully Reconciled, Discrepancies Found, Pending Review)
[ ] Description of Identified Discrepancies
[ ] Premium Reconciliation Report
[ ] Financial Auditor Signature

--- REGULATORY & STATUTORY COMPLIANCE ---
[ ] Regulatory Jurisdiction (Domestic, International/Cross-Border)
[ ] Last Regulatory Audit Date
[ ] Compliance Certifications Verified (GDPR/Data Privacy Compliance, SOC2 Type II Certification, ISO/IEC 27001, State-Specific Insurance License Verification)
[ ] TPA Regulatory License Certificate
[ ] Identified Compliance Gaps & Remediation Plan
[ ] Compliance Officer Attestation

--- OPERATIONAL PERFORMANCE & SCALABILITY ---
[ ] Current TPA Processing Volume Status (Within Capacity, At Capacity, Exceeding Capacity)
[ ] Average Claims Turnaround Time (Days)
[ ] Scalability Infrastructure Verified (Cloud-based Autoscale Enabled, Automated Workflow Triggering, Redundant Server Architecture, API Integration Readiness)
[ ] Identified Operational Bottlenecks
[ ] Last Capacity Stress Test Date

--- CUSTOMER EXPERIENCE & COMMUNICATION QUALITY ---
[ ] Average Claim Response Time Rating (Excellent (< 24 hours), Good (24-48 hours), Acceptable (48-72 hours), Unacceptable (> 72 hours))
[ ] Communication Channels Monitored (Email, Phone/Voice, SMS/Text, Customer Portal, Live Chat)
[ ] Summary of Recent Customer Complaints
[ ] Net Promoter Score (NPS) Recorded
[ ] Customer Satisfaction Survey Samples
[ ] Last Quality Assurance Review Date

--- SUBROGATION & RECOVERY MANAGEMENT ---
[ ] Subrogation Potential Identified (Yes, No)
[ ] Third-Party Liability Details
[ ] Date of Incident
[ ] Estimated Recovery Value
[ ] Required Documentation Attached (Police Report, Damage Photos, Third-Party Contact Info, Expert Assessment Report)
[ ] Evidence & Correspondence Files
[ ] Recovery Status Summary
[ ] Claims Adjuster Verification

--- BUSINESS CONTINUITY & DISASTER RECOVERY ---
[ ] Disaster Recovery Plan Status (Active & Tested, Under Development, Outdated/Needs Review, Not Available)
[ ] Last Disaster Recovery Drill Date
[ ] Upload Latest DR Test Results Report
[ ] Critical Redundancy Systems Verified (Offsite Data Backups, Secondary Communication Channels, Redundant Server Infrastructure, Emergency Contact Directory)
[ ] Identified Vulnerabilities & Mitigation Plan
[ ] Compliance Officer Validation

--- AUDIT TRAIL & DOCUMENTATION INTEGRITY ---
[ ] Audit Review Date
[ ] Documentation Completeness Score (Fully Compliant, Minor Deficiencies, Critical Gaps Identified, Non-Compliant)
[ ] Verified Audit Trail Components (Timestamped Transaction Logs, Decision Support Documentation, Authorized Signature Records, Email Correspondence Logs, Updated Policy Endorsements)
[ ] Evidence of Documented Discrepancies
[ ] Detailed Findings and Corrective Action Plan
[ ] Auditor Authentication

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