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Third Party Administrators (TPA) is the intermediary between Insured and Insurance Company. These TPA companies are BPO of insurance companies and responsible for all aspects of claim arising out of health insurance policies.
TPA company which typically file the claims for insured and also certify insurability for the insurance company. It means that TPA which works for both Insured and Insurance Company. These companies are licensed by Insurance Regulatory and Development Authority of India (IRDA).
Role of TPA is to coordinate with hospitals respect of treatment and also pass the bills on behalf of insurance companies. But the actual payment of claims is done by insurance company only.
Introduction of TPA is great help and relief to the insurance companies. TPA performs all functions which are required in the process of a particular claim.
Once policy has been issued work of TPA starts thereafter. Insurance company passes all the all records to the TPA and all further correspondence of the insured will be with TPAs and not with insurance company.
TPA which are expected to provide value added services to policyholders such as medicines and supplies, arranging ambulance services, guiding and helping insured with queries, 24 hour help lines, health facilities, bed availability etc.
Functions of TPAs ( Cashless Claim):
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TPA issues ID cards to all their policyholders in order to validate their identity at the time of admission.
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In case of claim, policyholder will have to inform TPA on their 24 hr toll free line.
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After informing TPA, the policyholder will be directed to a hospital where the TPA has a tied up arrangement.
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TPA pays for treatment; they issue authorization letter to the hospital for admission of policyholder.
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At the time of discharge all the bills will send to TPA to analyze case of insured at hospital.
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Then TPA makes the payment to hospital.
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TPA sends all necessary documents of claims to insurance company.
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Insurance company then reimburses TPA.
With help of TPAs, insurance companies able to provide better service to their policyholders as burden of claim settlement passes on to TPA. TPA which helps insured as well as insurance companies and ensures higher efficiency in the process of claim settlement.
Know more about health insurance in India.
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