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TPA (Third Party Administrator) for Claims and Cashless Health Insurance

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A Third Party Administrator (TPA) is an organization which processes claims or provides cashless facilities as a separate entity. Seen as an outsourcing of claim processing, TPA processes claims for both retail and corporate policies. The risk of loss incurred remains with the insurance company. The insurance company usually contracts a reinsurance company to share its risk. An insurance company hires TPA to manage its claims processing, provider network and utilization review. While some TPA operates as units of insurance companies, most are often independent.
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TPA is also involved in handling employee benefit plans such as processing retirement plans. Handling healthcare or employee benefit claims requires using a specialized set of manpower and technology, therefore hiring a TPA for the same is a more cost effective method.

Third Party Administrator (TPA) for Claims and Cashless Health Insurance

The Insurance Regulatory and Development Authority of India (IRDA) defines TPA as a Third Party Administrator who, for the time being, is licensed by the Authority, and is engaged, for a fee or remuneration, in the agreement with an insurance company, for the provision of health services. TPA was introduced by the IRDA in 2001.

Being one of the prominent players in the managed care industry, it has the expertise and capability to administer all or a portion of the claims process. The services include claims processing, premium collection, enrollment and cashless processing. Insurance companies setting up its own health plan often outsource certain responsibilities to a TPA.

The TPA acts like a claims adjuster for the insurance company. In some cases the insurance company sets up an entire department within their own company to act as TPA as opposed to hiring a commercial TPA company.
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Kindly let me know if it is obligatory to have the services of TPA while purchasing the Mediclaim Policy?Kindly reply at the earliest as I am to renew my Mediclaim Policy next month,and I am not happy with the services of my existing TPA.Kindly also let me know,whom to complaint against the TPA for the unsatisfactory services of TPA. An early reply to my querry will be a big favour as I understand that the fee payable to TPA is by the Policy purchaser.
tcjn74 Monday, November 24, 2014
Health insurance consists of Pre Hospitalisation, Hospitalisation and Post Hospitalisation. But normally it is seen that Pre and post hospitalisation are not cared by TPAs. They pay only for hospitalisation in cashless claims to hospitals. If in a cashless claims, if an insured is late to intimate to TPA while still in Hospital, the tPA does not entertain cashless service. What are the reasons ?
B.R.Khanna Friday, January 25, 2013
Q. MY FATHER WAS ADMITED IN APOLLO HOSPITAL, KOLKATA ON 17.1.2013 AT 2.45PM, AND RELEASED ON 21.1.2013 AT 9.45AM. HOSPITAL AUTHORIYT SEND THE FINAL BILL AT 10.00AM ON 21.1.2013 FOR CASHLESS APPROVALTO TPA [Emeditek] FOR 5 (FIVE) DAYS. BUT TPA SEND THE APPROVAL AT 4.30PM FOR 4 (FOUR) DAYS, BECAUSE THR 5TH DAY NOT COVERING 24 HOURS. WHAT IS THE RULE OF IRDA and AM I CASH BACK FOR THE 5TH DAY'S AMOUNT ON REIMBURSEMENT BASIS?
Guest Thursday, January 24, 2013
You have stated in the third para related to TPA that TPA also collects premium.Is it permitted by IRDA regulations for TPAs?
brkhanna Monday, April 30, 2012
1. With in maximum how many hrs or days TPA must sanction cashless request from a empaneled hospital against valid policy?? 2. With in maximum how many days claims are supposed to be settled as per IRDA guidelines?
tholiya Sunday, August 28, 2011

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