Third Party Administrators for Facilitating Insurance Services

Third Party Administrators is an important link between Insurance companies, policyholders & healthcare providers in servicing health insurance.

Core Activities of a TPA:

1. Record maintenance of policies of an insurer

2. Issuing identity cards to all the policyholders

3. 24 hour toll free line

4. Building up a provider network

5. Tracking fraudulent claim cases

6. Issuing Cashless facility to insured

7. Handling reimbursement claims

8. Managing payment to hospitals

TPAs are remunerated by insurers and remuneration is fixed on mutually agreeable terms. However IRDA lays down a maximum ceiling on the commission that can be given to a TPA, which stands at 15 percent of the premium amount. Each TPA may tie-up with any number of insurers and like wise each insurance company can empanel any number of TPAs.

Steps followed in the basic functions of TPA:

1. Cashless Facilitation Procedure

Receipt and Record of Member Enrollment
Issuance of unique ID Card
Providing with the reference list of network hospitalszoffering cashless facility
Receipt and securitization of pre-authorization request
Pre-Admission Authorization after checking Doctor Prescription, Admission Form, Hospital Information
Claim form should be submitted with original bills along with prescription, diagnostic reports and discharge summary.

2. Claim Reimbursement

When the insured goes to a Non Network Hospital and makes the payment for all hospital expenses all by himself, then he needs to submit all the original documents of treatment viz.:

ID/ Policy Card No. or Policy Number
Policy copy (if available)
Date of Hospitalization
Reason for Hospitalization
Date of Discharge
Claim Form (available on TPA website) – duly Filled and signed by the claimant policy holder
Medical Certificate Form duly filled by the treating doctor
Original Discharge Summary
All the Original Bills with break up
All Original Diagnostic Test Reports performed n patient during hospitalization
All Medical Bills accompanied by the prescriptions

TPA will assess the validity of claim based on the date on which the documents were submitted in correspondence to admission date and respond as follows:

'Claim settled': which means the Discharge Voucher will be sent.
'Document Shortfall': which means some more documents or other documents has to be furnished by the insurer.
'Claim Rejected': Rejection Letter will be sent.

3. Claims Control