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What is a Health Insurance TPA?

TPA(Third Party Administrator) in health insurance, is an entity which coordinates between the hospital and the insurance company. A health insurance TPA plays a key role in the case of both cashless and reimbursement health insurance claims.

 

They ensure that the claim process is carried out in a smooth and hassle-free manner and also provide support to the policyholders. The TPA can either be an independent entity or an entity affiliated with the concerned insurance company itself. Every health insurance TPA is mandatorily required to be registered with the Insurance Regulatory and Development Authority of India (IRDAI).

 

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What is a Health Insurance TPA

TPA (Third Party Administrator) in health insurance, is an entity which coordinates between the hospital and the insurance company. A health insurance TPA plays a key role in the case of both cashless and reimbursement health insurance claims.    They ensure that the claim process is carried out in a smooth and hassle-free manner and also provide support to the policyholders. The TPA can either be an independent entity or an entity affiliated with the concerned insurance company itself. Every health insurance TPA is mandatorily required to be registered with the Insurance Regulatory and Development Authority of India (IRDAI).

What is a Third Party Administrator? 

In simple terms, a third-party administrator (TPA) is a person, organisation or entity that serves as an administrator between two parties. Under health insurance, a third party is any entity that is not the insurance provider or the policyholder. In this article, we’ll take a closer look at what role a third-party administrator plays in health insurance.

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Role of Third Party Administrator In Health Insurance? 

To ensure smooth processing of health insurance claims and to help insurance companies provide top-of-the-class services for all policyholders is the job of a TPA i.e., Third Party Administrator. TPAs are licensed entities by the Insurance Regulatory Development Authority of India (IRDAI), tasked with the sole purpose of processing health insurance claims on behalf of the concerned insurance company. TPAs can either be affiliated with one or more insurance companies, or be an independent organisation altogether. 

Here are some of the roles that the TPA i.e., Third Party Administrator plays when it comes to health insurance policies: 

  • Claim settlement

Right from handling paperwork and presenting documents during claim to offering end-to-end support, a TPA is very integral to the entire claim settlement process. These entities can help policyholders process both reimbursement and cashless forms of claim settlements. With the help of a TPA, the insurance company and the policyholder can communicate freely and share information that can enable a quick settlement of the insurance claim.

  • Connecting Link 

The TPA essentially serves as a link between the insured (policyholder) and the insurance company. Whenever there is a health insurance claim, be it reimbursement or cashless, the policyholder communicates with the TPA. The TPA offers a unique ID number to the policyholder, which is essential for claim settlement process. 

  • Record Keeping 

TPAs are also responsible for keeping a track of all documents related to the insurance policy of the insured. This is crucial especially during the claim settlement process, when the insured files for a reimbursement or cashless claim with a network hospital. 

  • Onboarding Hospitals

It’s the job of the Third Party Administrator to review the hospitals and do due diligence to see if the hospital in question meets the criteria of their affiliated insurance company. Once the review is satisfactory, the TPA then onboards them as an empanelled hospital with their insurance company, and adds it to their list of network hospitals for policyholders to avail of claim settlement.

  • Dedicated Support 

There are TPA executives appointed with the intent to offer 24x7 service and support to policyholders. For any insurance claim-related doubts, details on non-network and network hospitals, ideal type of claim settlement, etc., policyholders can directly connect with the customer support team of their appointed TPA.

  • Additional Services 

Additional services of the TPA can also include but are not limited to offering ambulance support, supplying medicines, helping with exit paperwork, etc., for the policyholders.

What Are The Benefits Of TPAs In Health Insurance? 

Third Party Administrators in health insurance can make the claim process easier for policyholders. Here are the major benefits of TPAs in health insurance:

  • Standardisation of the Claims Process

Since health insurance TPAs follow a standard procedure to process and verify health insurance claims, the whole process becomes more streamlined. This leads to the swift settlement of claims, which is beneficial for both the insurer and the insured.

  • Support to the Policyholders

Another benefit of TPAs in health insurance is that policyholders can seek their support through a 24x7 helpline number. Therefore, any doubts that policyholders may have vis-a-vis the claims process can be readily addressed.

  • Awareness of Health Insurance Benefits

Policyholders can become more aware of the various benefits available under their health insurance policy with the help of TPAs by communicating with them to help understand the policy terminology better. 

  • Elimination of Fake Claims

With the expertise of health insurance Third Party Administrators, fake and fraudulent claims can be identified during the processing of the claims. This can be beneficial for the insurer in terms of savings of time and cost alike.

How Third Party Administrator Works?

The Third Party Administrators offer a smooth and hassle-free claim settlement process to the insured, be it cashless claim or reimbursement claim settlement. They play a crucial role in simplifying the claim settlement requests, thereby helping both the policyholders as well as the concerned insurance company. Here’s how the TPAs work in both type of claim settlements – 

  • Cashless treatment claim

When a policyholder directly allows the insurance company to settle the medical bills and hospital expenses, it is known as a cashless claim settlement. In this case, the policyholder has to contact their TPA for claim settlement. The TPA then offers end to end support, from choosing the right network hospital to closing the paperwork and settling expenses on behalf of the policyholder. 

  • Reimbursement claim 

When an insurance policyholder pays their medical bills and hospital expenses by themselves, and then raises a reimbursement request with the insurance company, it is known as a reimbursement claim settlement. In some cases, policyholders decide to opt for non-network hospitals for their treatment, and they inform the Third Party Administrator accordingly. Post discharge, when the insured files for a reimbursement claim, the TPA guides the policyholder with the set of required documents and the claim approval process. The insurance company finally transfers the claim amount to the insured’s bank account once the settlement process is complete.

How TPAs in Health Insurance Help Companies 

The TPA is licensed by the Insurance Regulatory Development Authority of India i.e., IRDAI, and they are either selected by the health insurance company themselves or some health insurance companies also allow customers to select from a list of TPAs registered with them. A Third Party Administrator also has the liberty to be linked with more than one insurance companies at the same time.

  • The Third Party Administrator is an intermediary between the insured (the policyholder) and the insurance company. In simpler words, the TPA is the bridge between these two parties, when the insurance claim is filed.

  • The key objective of the TPA is to ensure that the insurance claim made by the insured is processed in a hassle-free manner. 

  • It’s their job to make it easier for insurance companies by taking charge of the insured’s paperwork, settling hospital bills, offering end to end support in the claim process, etc. 

With the help of TPAs, insurance companies can provide dedicated and timely claim settlement support to their policyholders. Hence, it is crucial for insurers to choose their TPAs wisely.

How TPAs in Health Insurance Help Policyholders 

The TPAs provide the following valuable benefits to the policyholders: 

  • Support and hand holding during the hospitalisation process. 

  • Providing unique ID numbers and cards to the policyholders that are vital for cashless claims. 

  • Assistance related to gathering and storing the right documentation.

  • Support in the cashless claims process in case any issues arise. 

  • Simplification of the entire claim settlement process.

Cancellation Of TPAs In Health Insurance (In table format with features and benefits)

The Third Party Administrators are generally provided by the health insurance companies or the policyholder is allowed to select from the list of TPAs that are registered with the insurer. Hence, it is important for the policyholders to keep a few things in mind –

  • The TPAs can be cancelled or changed by the insurance company at any time, and the insured i.e., policyholder can get in touch with them to know more details. 

  • The insurance company keeps its policyholders updated on the active TPAs that are affiliated with their company, replacement or exit of a particular TPA, etc.

  • Your insurance company will be your primary point of contact for all queries and can redirect you to your updated TPA as well, when you file for a claim.

List of Health Insurance TPAs

Here is the list of the popular health insurance Third Party Administrators operating in India: 

 

  • United Healthcare Parekh TPA Private Limited

  • Media Assist India TPA Private Limited

  • MD India Healthcare (TPA) Services Private Limited

  • Paramount Health Services & Insurance TPA Private Limited

  • E Meditek (TPA) Services Limited

  • Heritage Health TPA Private Limited

  • Focus Healthcare Services TPA Private Limited

  • Medicare TPA Services (I) Private Limited

  • Family Health Plan (TPA) Limited

  • Raksha TPA Private Limited

  • Vidal Health TPA Private Limited

  • Anyuta TPA in Healthcare Private Limited

  • East West Assist TPA Private Limited

  • Med Save Health Care TPA Private Limited

  • Genins India Insurance TPA Limited

  • Alankit Insurance TPA Limited

  • Health India TPA Services Private Limited

  • Good Health TPA Services Limited

  • Vipul Med Corp TPA Private Limited

  • Park Mediclaim TPA Private Limited

  • Safeway Insurance TPA Private Limited

  • Anmol Medicare TPA Limite

  • Dedicated Healthcare Services TPA (India) Private Limited

  • Grand Health Care TPA Services Private Limited

  • Rothshield Healthcare (TPA) Services Limited

  • Ericson Insurance TPA Private Limited

  • Health Insurance TPA of India Limited

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FAQs on TPAs In Health Insurance

✔️What is a Third Party Administrator in health insurance?

A Third Party Administrator in health insurance is an entity that carries the responsibility of the efficient and hassle-free processing of health insurance claims.

✔️Where can I check the list of the active TPAs of my health insurance provider?

You can check the list of the TPAs for your health insurance provider by visiting their official website or checking your health insurance card.

✔️What types of health insurance claims do TPAs deal with?

Third Party Administrators deal with the following main types of health insurance claims – (i) Cashless claims and (ii) Reimbursement claims.

✔️Can a particular TPA be canceled?

Yes, a particular TPA can be cancelled by your health insurance provider or de-licensed by the Insurance Regulatory and Development Authority of India (IRDAI).

✔️Do health insurance TPAs offer customer support?

Yes, a role of TPA in health insurance is that they provide customer support through their 24x7 toll-free helpline number.

✔️What is the difference between TPA and insurance companies?

 Usually, the insurance companies allow the customer i.e., policyholder to choose their Third Party Administrator (TPA) from a list of TPAs that are registered with them. These TPAs work as the intermediary between the insured individual and the company providing insurance. The TPA selected by the policyholder will then take charge of the claim settlement process of the insured, and not the insurance company itself.

✔️ Can a single Third-Party Administrator work with many insurance companies?

Yes, it is possible for a single TPA i.e., Third Party Administrator to be affiliated with more than one insurance company at the same time.