Everything to Know About Third Party Administrator (TPA) in Health Insurance

Have you met any case of emergency hospitalization of your dear one? Though bitter, it is an arduous and unavoidable factor in our life. At the time of any uncertainty or accident (that requires immediate hospital care), you end up rushing for medical aid. Those with a health insurance plan have time to breathe, but those with no such plan face a financial strain. While we have so many insurers to buy health insurance, a Third Party Administrator (TPA) helps us by resolving several issues related to health insurance claims. As soon as you or an insured person is hospitalized, intimation is given to the TPA.

What is a Third Party Administrator?

Dig deeper to get insights into TPA and their roles.

A Third Party Administrator or TPA is a body that is engaged in processing insurance claims. Though they are self-governing, they act as an entity belonging to the insurance company. These bodies get a license from the Insurance Regulatory IRDAI. Over the last few years, the number of health plans sold, insurers, and type of products and buyers has increased in considerable proportion. As a consequence, it is hard to work which did not result in quality services. It is due to the fact that IRDIA came forward with the Third Party Administrators.

Eventually, it got difficult to keep track of work which did not result in quality services. Therefore, the insurance regulatory, IRDA introduced the Third Party Administrators.

How TPA Helps You?

  • A TPA is an intermediary between you and your insurer
  • It simplifies the claim procedure under health insurance policies
  • As soon as you are admitted to a hospital, intimate the TPA or the insurer about the admission
  • The TPA then asks the hospital to arrange for a cashless facility, if possible
  • Otherwise, it will process for reimbursement
  • The TPA scrutinizes the bills and other documents post
  • In cashless treatment, the payment will be made to the hospital
  • But for the reimbursement, you will receive the expenses from your insurance company

Relevance of TPA

ATP has the capability to take care of all hospital bills, and other expenses. While your family member or individual needs hospitalization, you can just end up taking care of them. TPA will help you by handling the rest tasks. Note down that every insurance company designates a TPA for your service. You don’t need to pay directly to the administrator. A TPA can either approve of cashless claim settlement or reimburse your amount. As a policyholder, you can communicate with your insurance company only. TPA is responsible for

  • Sharing endless knowledge of healthcare services.
  • Improvising the quality of services.
  • Managing and investigating any claims.
  • Monitoring the Cashless and Reimbursement claim.

Role of TPA in Health Insurance

A TPA has a vital role to play when it comes to the total processing of health insurance claims. Some of the key jobs of TPA include the following.

Health Cards Issuance – One of the jobs of TPA is to issue health card to the insured. Generally, a validation of procedure is carried out to issue a policy to customers. This card contains the details of the policy numbers and the TPA which is solely responsible to process claims. While getting admission to a hospital, the insured person needs to produce this card and intimate the occurrence of the claim to the insurer or TPA. Your health card is the most essential documents required for the claim processing. However, it is important to note that many insurance companies are issuing e-card these days which serves the purpose of a traditional card.

Value-Added Services – TPA also takes care of arranging value-added services. These services include well-being programs, ambulance, and others.

Claim Processing and Settlement –  A TPA speeds up the claim process. They process the claim soon after getting intimation from the insurance company. They are responsible for checking all the documents submitted in favor of the claim. They can ask for as much information as required to conduct cross-verification of all the details. The claim settlement can be done either on a cashless or a reimbursement basis. Whichever the case, the TPA will verify all the documents. When it comes to cashless claim, they collect all the documents from the hospital. In case of reimbursement, they can ask for supporting documents papers and bills from the policyholder.

Hospital Networks – Apart from the above responsibilities, TPA also helps in strengthening the hospital network, which is a crucial aspect of every health insurance company. Further, they build a strong network of hospitals that allow policyholders to take cashless treatment. The TPA are responsible for enlisting all the best hospitals that can quickly arrange for cashless treatment and allow the negotiation of the rates.

Helpline Facility – As an insured person, you can get all the information and any type of assistance related to your claim by calling the TPA service. The TPA facility is operational 24X7 for customer service and it can be called from anywhere in India. With their availability, you are able to know the status of other claims also. A toll-free number of TPA service providers are available on the home page website of your insurance company.

The bottom line is that TPA service plays a very important role. It performs as a mediator between the policyholder and the insurance company. Please note that they some health insurance companies that have no TPA. They handle everything themselves.

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