Third Party Administrators for Health Insurance

1. Support for Claim Settlement: TPAs serve as an essential conduit between the insured person and the insurance provider during the post-hospitalization of claim settlement procedure 

1. Insurance companies choose TPAs to handle their claims, guaranteeing that there is a specialized organization to support policyholders 

1. Third-party administrators offer ID cards to insured persons, which must be produced at hospitals to settle cashless claims 

1. Hospital Choice Flexibility: While policyholders can choose any hospital for treatment, choosing a non-network hospital means they cannot submit a cashless claim and must pay out-of-pocket first 

1. Effective Claim Settlements: Insurance firms collaborate with TPAs to guarantee seamless claim settlement procedures, improving client satisfaction. 

List of TPAs Empaneled with Health Insurance Companies

The list of IRDAI-licensed third party administrators are as follows:

Now, we will have a detailed list of Third Party Administrators available in India:

Documents Required for TPA Claim Settlement in Health Insurance

The following are the documents needed to make a TPA Health Insurance Claim: 

1. Aadhar Card
2. The insurance copy of the policyholder
3. Health Insurance TPA e-card
4. Pharmacy and hospital discharge bills or receipts
5. Doctor’s prescriptions

1. Hospital discharge documents

Benefits of TPA in Health Insurance 

Here are some of the benefits of having a TPA in health insurance: 

1. A TPA assists policyholders in filing insurance claims, saving them time and effort 

1. A TPA helps policyholders understand their insurance features and gives information on hospitals, doctors, and medical facilities covered by their policy 

1. The TPA helps to manage insurance claims, making the claim process easy and efficient 

1. TPAs have a panel of doctors available to give medical assistance to policyholders on a priority basis 

1. TPAs have a network of facilities that policyholders can visit for medical care, offering a cashless facility to reduce financial stress. 

How do TPAs in Health Insurance Help Policyholders?

TPA in health insurance offers a wide range of services and benefits to the insurance policy holders. Given below are the some of the key advantages provided by TPAs: 

1. For policyholders, the claim procedure is simplified and hassle-free. TPAs ensure that all claims are processed efficiently while keeping policy terms and conditions, resulting in a more seamless experience 

1. TPAs can answer policyholder questions, assist with claiming process, and contact the insurance company on the policyholder's behalf. They offer the policyholder individualized services 

1. Policyholders can take advantage of cheaper rates and cashless hospitalization services because TPAs usually have partnerships with the majority of the network of hospitals. 

How to Change or Cancel a TPA in Health Insurance?

TPA acts as a facilitator. Additionally, if there is a delay in the services being rendered, you can get in touch with your insurance company, who get in touch with the TPA and update you on the situation. You may talk to your insurer about changing your TPA if you decide you want to cancel one or transfer to another one. The following are the steps to cancel the TPA in health insurance: 

1. Firstly, you have to get in touch with your insurance company either via call or email. 
2. Next, share your policy details as well as your unique ID. 
3. Inform your insurer about the reason for requesting a TPA change or cancellation. 
4. Once your insurance company approves the change of TPA, you can select another TPA from the list. 

Difference Between TPAs and Insurance Providers

Here is the difference between TPAs and Insurance Provider as follows: 

Why Are Third Party Administrators Important in Health Insurance?

According to industry observers, TPAs can bring in the following changes:

1. Greater efficiency/quality (delivery of services)
2. Improved standardisation (procedures and due diligence)
3. Increase knowledge base of healthcare services
4. New management system
5. Greater penetration of health insurance
6. Minimize costs/expenditure
7. Develop protocols to streamline investigation and avoid unnecessary delays
8. Pave way for lower insurance premiums
9. Support operational efficiency, which may indirectly contribute to more competitive insurance pricing

How do TPAs Function?

There are two scenarios on how TPAs function. Given below are the details of the two scenarios: 

Cashless Treatment at Network Hospitals :

1. When a policyholder requires a medical treatment, they can visit a hospital which is a part of the network of insurance company. 

1. The hospital will send the details of the treatment and approximate costs to the TPA. The TPA officials will verify the eligibility of the policyholder and the coverage provided under the insurance policy.
2. If everything is right, the TPA will provide the pre authorization to the hospital through which the policyholders can receive treatment without paying any upfront. 
3. The TPA will then settle the payment with the hospital on behalf of the insurance provider once the hospital bills it directly for the expenses of the care. 

Reimbursement for Non-Network Hospitals :

1. If a policyholder gets a treatment from a non network hospital, he or she has to pay an upfront cost and then file a reimbursement claim with the insurer. 

1. The policyholder will have to submit all the required documents as well as bills to the TPA after which the TPA officials will verify the details and process the claim. 
2. Next, the TPA will send the claim to the insurer for approval as well as reimbursement. 
3. Once the claim has been approved, the TPA will reimburse the amount either by issuing cheque or by doing direct bank transfer to the bank account of the policyholder.