Third Party Administrators for Health Insurance
Services offered by the TPA
The TPA undoubtedly aims to give the health insurance industry the required boost in India.††
The services provided by TPA are as follows:
- ID card: TPA provides ID cards to all their policyholders in order to validate their identity at the time of admission.
- The TPA's undertakes "Pre-authorization" before a surgical procedure to ease claim processing
- 24 hours customer support services: The TPA provide assistance through their 24 hrs call center that provides information regarding policyholder's data, provider network, claim status, benefits available with existing cardholder, etc All these details are furnished on request.
- Cashless Hospitalization: Each policyholder is provided with a list of empanelled hospitals where in he/she can avail cashless hospitalization.
- Claim Management: On behalf of the insurance companies TPA administers and settles claims for hospitals and policyholders.
Policyholders have the privilege of expressing their grievances to the concerned insurance company or at the consumer's court if they are not satisfied with the services of a TPA.
†The specialized functions of the TPA include:
- The TPA keeps and maintains all the records of medical insurance policies of an insurer. †
- The TPA issues identity cards to all the policyholders. The policyholders will have to show the identity cards to the hospital authorities before availing any services from the hospital.
- In case of a claim, policyholders will† have to inform the TPA on a 24 hr toll- free line provided by them
- After informing the TPA, the policyholder will be directed to a hospital where the TPA has a tied up arrangement. However, policyholders have the option to be admitted at another hospital of their choice in which case, payment will be on reimbursement basis.
- TPA pays for the treatment; they issue an authorization letter to the hospital for the admission of the policyholder in the hospital.
- At the point of discharge, all the bills will be sent to the TPA while they are tracking the case of the insured at the hospital.
- TPA makes the payment to the hospital.
- TPA sends all the documents necessary for consideration of claims, along with the bills to the insurance company.
- The insurance company then reimburses the TPA