Role of TPA in Health Insurance
Published On Feb 13, 2023 10:30 AM By InsuranceDekho
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Medical emergencies can occur at any time. And health insurance is an important tool that provides a feeling of reassurance to policyholders. During those tough times, you may particularly want to focus on the health of your loved ones and therefore may require additional help for claim settlement. Here’s when third-party administrators help you. In simple terms, a third-party administrator is an entity or a person that coordinates between the hospital and the insurance company for cashless and reimbursement claims. Read on to learn about third-party administrators (TPA) in detail!
What is TPA in Insurance Sector?
A third-party administrator (TPA) is a person, organization, or entity that administers between an insurance company and a hospital for the purpose of making the claim settlement process smooth for the policyholders. Each TPA in India must be registered with the Insurance Regulatory and Development Authority of India (IRDAI). The TPA is responsible for providing high-quality, consistent services to the policyholders.
Role of TPA in Health Insurance
TPA plays a major role during your health insurance claim settlement process. Some of the crucial activities performed by third-party administrators are listed in the section below.
Provides Health Card to the Insured:
A health card is a mandatory document required during a claim settlement process. Each policy that is issued to policyholders goes through a validation process. Upon completion of the process, an authorized health card is issued that contains your policy number and details of your TPA. During hospitalization, the policyholder can use this card to initiate the claim settlement process either with the insurer or TPA.
Ensures Smooth Claim Settlement:
TPA provides end-to-end support to the policyholders at the time of the health insurance claim settlement process. Whether you’re making a cashless claim or a reimbursement claim, TPA plays an integral role in claim settlement. They cross-verify all the documents and details submitted by the policyholders.
Strengthens Network Hospital:
One of the most crucial benefits of a health insurance policy is having a third-party administrator by your side. They establish a strong hospital network where policyholders can receive cashless treatment.
Provide Dedicated Support:
TPA executives are available to policyholders 24 hours a day, seven days a week. If you have any questions about health insurance claims, network hospitals, or anything else, you can contact customer service for answers.
Keep the Track of Documents:
All the documents related to the insurance policy are held by third-party administrators. This is essential during a claim settlement process regardless of making a reimbursement or cashless claim with a network hospital
How Does a Third-Party Administrator Work?
Third-party administrators provide a seamless claim settlement process for the policyholders. Whether you’re making a cashless or reimbursement claim, TPA will help you. Here’s the process that you can follow in each case.
- Cashless Claim:
When a hospital directly settles the medical bills and hospital expenses with the insurance company. In this case, the insured has to contact their TPA for the claim settlement process.
- Reimbursement Claim:
Under this type of claim settlement process, the policyholder pays all his bills and other medical expenses. Further, he claims reimbursement under their health insurance policy In some cases, the policyholders get treatment at a non-network hospital and inform their TPA to claim their bills. The policyholder needs to provide all the necessary documents to the TPA for verification.
Third-party administrators ensure that the policyholders can experience a seamless claim settlement process. However, you can also cancel or change third-party administrators' services at anytime.