TAHP · TX Covered 2026

What's your payment accuracy gap costing you?

Provider data and configuration accuracy drive two costs most plans underestimate: pend-processing overhead and denial rework. Adjust the inputs below to see your plan's exposure.

Your Plan — Adjust the Inputs
Plan Membership 100,000
Total enrolled members
10K1.5M
Claims per Member per Month 2
Varies with your line-of-business mix
0.54
Auto-Adjudication Rate 75%
Best practice is above 85%. Vendor says 90%+? Ask what they're counting.
55%95%
Initial Denial Rate 11.8%
2024 industry avg = 11.8% (Kodiak, via HFMA)
5%20%
Locked Assumptions
$0.90 auto-adj cost/claim
$20.00 pended claim cost
$47.77 denial admin cost (MA)
50% denials tied to data (assumed)
Your Estimated Exposure
Pend Cost Gap Healthcare Finance News
Annual claims 2,400,000
Pended claims 600,000
Annual pend bill $11,460,000
Tied to provider data (≈1 in 4) $2,865,000
vs. 85% auto-adj benchmark —
Denial Rework Cost Kodiak via HFMA; Premier
Denied claims / yr 283,200
Total denial admin cost $13,530,240
Data-driven denials (50%) 141,600
Rework cost, data-driven denials $6,765,120
Combined Estimated Exposure
Pend cost gap + data-driven denial rework
Provider data and configuration accuracy are material drivers of both figures.
$8.67M

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Cost per claim: about $20 to finish a pended claim versus well under a dollar auto-adjudicated (modeled at $0.90), per Healthcare Finance News. The annual pend bill is the extra cost of pended claims over auto-adjudicated ones; the 1-in-4 provider-data share is a Maven One estimate. Denial rate: 11.8% of claims initially denied in 2024, from Kodiak Solutions data reported by HFMA. Denial admin cost: $47.77 per Medicare Advantage claim, the average cost to pursue a denial in a Premier Inc. survey of hospitals and health systems (2022 data). The 50% data-driven denial share is our assumption: in Experian Health's 2025 State of Claims survey, missing or inaccurate data was the top denial reason, cited by 50% of providers. Data quality covers more than provider data. Model is illustrative; actual plan results will vary.