Bespoke Health Consultancy

Why TPAs Reject New Clinics

TPAs decline or defer new clinics for a small number of recurring reasons: an incomplete or internally inconsistent provider file, services offered that fall outside the licensed activity list, clinician licensing or credentialing gaps, a price list that does not map cleanly to the expected coding standard, no evidence of claims and documentation capability, or network saturation in that catchment. Most of these are fixable before applying — network saturation is the one that is not.