TPA in Health Insurance

How Do You Benefit From A TPA in Health Insurance?

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The full form of TPA is Third Party Administrator. A third-Party Administrator in the insurance industry means an agency, organization, or company licensed by the Insurance Regulatory Development Authority of India or IRDAI to intermediary the insurer and the policyholder. 

TPA in health insurance means the Third-Party Administrator, which processes the health insurance claims of policyholders on behalf of the health insurance provider. TPA is the medium for many functions relating to health insurance. The massive increase in health policies, insurers, and buyers led to a big problem in keeping track of the policies and claims. As a result, TPA in health insurance came into being to manage the huge volumes of health insurance policies. 

Apart from health insurance companies, owners of private organizations providing health benefits to their employees can also hire third-party administrators. Employers financing the costs of medical treatments of their employees can enlist the services of TPAs to process claims and keep records of the employees on their behalf. 

What Is the Role of TPA in Health Insurance?

TPA Simplifies the Claim Settlement Process

Simplifying the process of settling claims for the policyholders is the major role of TPA in health insurance. The policyholder needs to intimate his/her TPA in the event of medical treatment necessitating hospitalization. The TPA collects all the documents in favor of the claim and seeks additional details if required. TPA in health insurance submits the documents with the insurer and expedites the claim processing. The TPA ensures cashless treatment in the case of networked hospitals or reimbursement in the case of a non-networked hospital.

Network Hospital

TAP Build a Strong Network of Hospital

Another important role of TPA in health insurance is to build a strong network of hospitals. TPAs work to enlist the best hospitals in the networks of their associated insurance providers. This ensures that the policyholders have many options of good hospitals to avail cashless treatment. TPAs also ensure that the networked hospitals meet the insurers’ necessary criteria, such as beds, medicine supplies, diagnostic services, etc.

TPA Issues Health Cards to The Policyholders

Health Insurance TPA issues health cards to the policyholders. The health card carries various details, including the policy number and the information about the Third-Party Administrator. The policyholder needs to produce the health care at the hospital to avail cashless treatment, and it is also an essential document for the claim processing.

Records of Policyholders

TPA Maintains the Records of Policyholders

Health Insurance TPA also maintains the records of policyholders, which are necessary for the health insurance policies. TPAs create and operate dedicated databases for storing the digital records of all the necessary documents. Thus, the function of TPA in health insurance is also to help insurance providers in lessening the burden of large volumes of documents.

TPA Maintains the Records of Policyholders

Health Insurance TPA also maintains the records of policyholders, which are necessary for the health insurance policies. TPAs create and operate dedicated databases for storing the digital records of all the necessary documents. Thus, the function of TPA in health insurance is also to help insurance providers in lessening the burden of large volumes of documents.

Customer Service Provider

Work as A Customer Service Provider

Customer service is also an important aspect of the role of TPA in health insurance. A 24/7 toll-free helpline is required to be made available by the TPA for the policyholders. The policyholder is free to call anytime to get information about health insurance TPA claim status, policy details and resolve other queries. Customer service by TPA eliminates the need for the policyholder to contact the insurer. However, in case of queries or complaints related to the Third-Party Administrator, such as delay in claim processing, the insurer must be contacted directly.

TPA in Health Insurance Also Offers Added Services

Apart from services raised to health insurance, TPA in health insurance also offers added services. These include ambulance services, health management programs, specialized consultations, and many more. 

What Are the Benefits of TPA for Health Insurance Policyholders?

Faster Claim Process

Make Claim Process Simple and Faster

Health Insurance TPA provides a plethora of benefits to the policyholders. The major benefit is the increase in efficiency of delivering health insurance to the policyholders by simplifying the claim process. The policyholder undergoing medical treatment simply needs to intimate the TPA.

In a networked hospital, the Third-Party Administrator scrutinizes the bills and other documents and pays the hospital if a cashless claim is approved. In the case of a non-networked hospital, the insurer reimburses the policyholder through the TPA. Whatever may be the case, the policyholder doesn’t need to do much for making a claim. 

Easy Claim Status Access

Easy Access of Claim Status

The role of TPA in health insurance is also to investigate the claims and ensure that all the documents are in order. This streamlines the claim settlement process for the insurance provider and prevents delays in claim settlements since the insurer does not need to utilize its resources. Health Insurance TPA Claim Status can also be checked easily by the policyholder by contacting the TPA and not the insurer.

Remove the Confusion to The Claim Process

Remove Ambiguity Related to Claim

The details of medical ailments covered by a health insurance policy are often ambiguous. It becomes confusing whether or not the policyholder can claim a particular kind of treatment. Health Insurance TPA solves this problem through qualified doctors hired by TPAs to determine whether a particular policy covers an ailment.

What Are the Benefits of TPA for Insurers?

TPA in health insurance not only provides benefits to the policyholders but also helps the insurers in many ways.

Reduce False Claims

Reduce False Claims

The role of TPA in health insurance regarding investigations of claims is highly beneficial for the insurance providers because it reduces the frequency of false claims. As a result, the claim ratios are also decreased. The treatment costs are also standardized. 

Reduce Claim Management

Reduce the Claim Management Cost

TPA in health insurance reduces the costs of claim management and total overhead costs. The control of the insurers over claim outcomes also increases significantly.

Improve Insurance Providers Reputation

Improve the Reputation of Insurance Providers

TPA in health insurance provides access to highly experienced and skilled claim administrators. As a result, the insurers can achieve more focused, efficient, and faster claim management, which benefits the policyholders and burnishes the reputations of the insurance providers.

Maintain Good Relationship

Maintain Good Relationship

Third-Party Administrators in health insurance act as a liaison between the policyholder and the insurer. The TPA’s customer service helps the insurer maintain a good relationship with its clients without utilizing its resources much. Thus, TPA protects the customer relationships of the insurer.

Protect from Financial Losses

Protect from Financial Losses

Health Insurance TPA detects frauds committed by private hospitals, such as inflated claims. Thus, the insurers are protected against financial losses due to possible fraud.

Do I Have to Pay Money to The TPA in Health Insurance?

The policyholder is not required to pay money to TPA in health insurance. The revenue generation model of TPAs does not include charges imposed on the policyholders.

  • The main source of revenue for TPAs is fees or commissions on premiums as per the guidelines of IRDAI.
  • Other sources of revenue include claim administration, data management, and medical management.

How Do I Change My TPA in Health Insurance?

  • Since 2019, IRDAI has allowed policyholders to select TPAs. Earlier, the customers were dependent on the insurers for third-party administrators. This is no longer the case because the insurer is now required to provide a list of its partner TPAs and the customer has the right to choose a TPA in health insurance from the given list.
  • The policyholder can change the TPA, but it can be done only at the time of renewal of the policy. The TPA cannot be changed during the coverage period. The policyholder can select a TPA from the list provided by the insurer only when buying or renewing a policy. In case the insurer terminates the services of the TPA during the coverage year, the policyholder has the right to select another TPA as per the guidelines of IRDAI.
  • The insurer must appoint a third-party administrator if the policyholder does not select one from the list provided. There are no options for TPAs for the customers if the insurer has a tie-up with only one TPA.
  • The number of TPAs to be provided to the customers depends upon the types of insurance products and the geographical locations of the policyholders.

How Do I Get My TPA ID?

TPAs provide ID cards bearing Unique Identification Numbers to policyholders. The Unique Identification Number printed on the TPA ID card validates the policyholder’s identity for the claim processing.

The insurer shares the policy details and other information of the policyholder with the TPA. Using this information, the third-party Administrator generates the unique identification number of the policyholder and issues an ID card. The TPA ID card is sent to the registered mailing address of the policyholder.

Most TPAs also provide e-Cards. The policyholder needs to access the website of the TPA and log in using various credentials such as unique identification number, policy number, name, etc. Post login, the policyholder is required to download the card from the given option. The e-Card can be either saved on the smartphone/computer or a printout can be taken.

In case of ID card loss, a letter requesting a duplicate ID card must be sent to the TPA. Charges need to be paid for the issuance of a duplicate ID card.

How Do I Check My Health Insurance TPA Claim Status?

1

Online Claim Status

It is very easy for a policyholder to check his/her health insurance TPA claim status. Health Insurance Third-Party Administrators usually provide digital facilities to check health insurance TPA claim status. The policyholder needs to access the website of the TPA and select the track claim status option. On the new page, enter details such as claim number and mobile number to get an instant update on the latest status of the claim.

2

Claim Status Toll-Free Helpline

TPAs also provide toll-free helpline numbers to get information about the claim status from customer care executives. Many TPAs also provide SMS facilities to check health insurance TPA claim status. The policyholder is required to send his/her claim number and other credentials by SMS to a particular number given by the TPA to get the instant update by SMS.

How to Cancel TPAs In Health Insurance?

The policyholders have the right to cancel the services of TPAs. If you are dissatisfied with the services of your TPA due to any reason, such as delays in claim processing, you can terminate that TPA and opt for another TPA during renewal.

The policyholder is required to contact the insurer through call or email and share their policy details and unique ID number. After that, a request to cancel the TPA needs to be made, and specific reasons must be given for cancellation. On approval of the request by the insurer, the policyholder is asked to select another TPA from the list.

What Are the Benefits of TPAs Over In-House Claim Processing by Insurers?

Wider Network Hospitals

The networks of hospitals of TPAs are much wider as compared to the in-house claim settlement departments of insurers. Thus, the TPAs offer far more opportunities to policyholders to avail cashless treatment across the country than the insurers’ in-house claim settlement departments. The largest TPAs have more networked hospitals than any insurance company.

Easy Claim Settlement

TPAs provided better claim settlement facilities because the whole process is streamlined and made easily understandable for the policyholders. The TPAs have no role in claim approval or rejection, but they ensure that making claims is correct and the insurers settle the claims as soon as possible.

Faster Claim Process

Contacting the TPA is faster, which is very beneficial for the policyholders, especially in an emergency. TPAs have their help desks in networked hospitals, which help their customers in contacting them quickly. The helpdesk acts as the point of contact for the customer with the TPA.

Common Question-Related TPA in Health Insurance

What Are the Documents Required for Mediclaim?

There is often much confusion regarding the documents required by the TPA to process cashless claims in a network hospital. The TPA seeks a number of documents from the hospital to process cashless claims. These include the claim form filed by the policyholder, original bills, and the discharge certificate. The policyholder is required to countersign the bills. The policyholder is not required to submit these documents and must leave the documents with the hospital itself. The TPA settles the hospital bill after the insurer approves cashless treatment.

In the case of a non-networked hospital or the event of rejection of a cashless claim in a network hospital, certain documents must be submitted with the TPA to claim reimbursement. These include duly-filled claim forms, discharge certificates, cash memos, reports of diagnostic tests, doctor’s certificate attesting to the diagnosis of the disease, certificate from the doctor that the patient is cured, and details of previous policies if any. The TPA reimburses the bills after approval from the insurer.

How Do Health Insurance Companies Find Out About Pre-existing Conditions?

Since health insurance policies do not cover pre-existing diseases, it is incumbent upon the TPAs to check whether or not the diseases are pre-existing. The panel of doctors of a third-party administrator scrutinizes the medical records of the claimant to determine whether the disease for which the claim is being made manifests before the activation of the policy or not. The claim is not accepted if the disease comes under a pre-existing category.

Can You Ask to Be Transferred to Different Hospitals?

TPAs allow the change of hospitals during the treatment period. However, the shift in hospitals is allowed only if the TPA finds it in agreement with the rules and regulations of the policy and is satisfied that the change is necessary.

The list of hospitals in the network of a TPA is provided to the policyholder, along with the ID card and guidebook. The policyholder can also download the list of network hospitals from the official website of the TPA.

How Do I Change My Name on My Health Insurance Policy?

In case of a change of name or other alterations in the policy document, the request for the same must be made to the insurer and not the TPA. TPA is the link between the insurer and the policyholder, but it is only the insurer who can make changes in the policy document.

Delay in TPA ID Card

It can happen that the insured person has received the policy document, but the TPA ID card is still not available. The common reason is the insurer’s delay in forwarding the person’s details to the TPA. In case of delay in receiving the card, the policyholder can visit the official website of the TPA and enter the policy number to know about the card status. The helpline number of the TPA can also be used to know about the status of a customer care executive.

Mistake in TPA ID Card

In case of any mistake in the TPA ID card, the policyholder should send the card back to the TPA with a request letter specifying the mistakes to be corrected. The TPA usually sends the corrected card to the policyholder within 7 days without any charge.

How to Choose TPAs?

As mentioned before, IRDAI allows policyholders to choose third-party administrators. Two factors must be considered while choosing a TPA.

  • The list of network hospitals of the TPA is an important consideration, and you should look for the hospitals near your location or the ones you prefer in the list of network hospitals of any TPA. This ensures that you can get cashless treatment easily for your medical needs.
  • Visit the official websites of various third-party administrators and compare their healthcare services. Apart from the conventional services, look for value-added services such as facilities during emergencies, wellness programs, ambulance services, mobile app services, etc. More the services, the better for you.
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