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Knowledge Base Health Insurance Third Party Administrator (TPA)
Friday, 11 February 2011 17:47

Third Party Administrator (TPA)

Written by  Yashish Dahiya
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Third Party Administrator (TPA)


Third Party Administrator is a company that manages insurance processes usually the service part on the behalf of insurer and receives commission in return. Insurance companies outsource some aspects of insurance business to make the process hassle free and efficient. TPA’s perform these services and acts as intermediary between the insurer and the insured. TPA’s could be division of insurers or completely autonomous.
TPA’s are regulated by IRDA and licence is granted for three years from date of issue until renewed.

TPA Services: TPA’s first role is to issue identity card with unique identification number and provide insured with a guidebook on claims process with a list of networked hospitals. The other functions performed by TPA are:

 

 1. Claims Process: TPA primary role is to process claims both cashless and claim reimbursement.

 
  1. Cashless Claims- The insured needs to provide the network hospital with TPA issued identity card or policy number. The hospital sends pre authorization details with doctor’s certificate, treatment details etc. If found  that claim is legitimate, TPA issues letter authorizing hospital to proceed specifying the maximum limit of cover. 
  2. Claim reimbursement- The insured needs to contact TPA as soon as possible and intimate about the claim. Documents like claim form, hospitalization details, diagnostic tests, treatment bills, policy duplicate should be provided to TPA. If found legitimate, TPA will reimburse the claim.

 2. Enlist Health Care Providers: TPA also ties up with hospitals to provide more comprehensive coverage to the insured. The selection criterion depends on location, infrastructure, facilities available etc.

 3. Customer Support: TPA maintains dedicated call centre to provide quick access to policyholders, respond to their queries and update about claim    status. TPA’s also have websites for online assistance.

  4. What are documents required in absence of cashless facility by TPA?

  • Claim form duly filled by claimant
  • Original Discharge summary from the hospital
  • Doctor’s consultation report, Specialist fees
  • Laboratory tests undergone by patient along with doctor’s authorization.
  • All medicals invoice along with doctor’s prescription
  • Any other document related to hospitalization
  • Policy copy if available


 What if TPA rejects claim?
 

TPA rejects claims if it finds the claim not being genuine. Whenever TPA rejects claim, the reason for rejection is also stated. However if you feel that TPA rejection is unjustified, you can contact your insurer within few days of rejection to present your concerns.

List of TPA’s:

1. Alankit Health Care TPA Limited

2. Anmol Medicare TPA Ltd.

3. Anyuta Medinet Healthcare TPA in Healthcare Pvt. Ltd

4. Dedicated Healthcare Services TPA (India) Private Limited

5. E Meditek (TPA) Services Ltd.

6. East West Assist TPA Pvt. Ltd

7. Family Health Plan (TPA) Ltd

8. Focus Healthservices TPA Pvt. Ltd

9. Genins India TPA Ltd.

10. Good Healthplan Ltd

11. Grand Healthcare Services TPA Private Limited

12. Health India TPA Services Private Limited

13. Heritage Health TPA Pvt. Ltd

14. I Care Health Maangement & TPA Services Pvt. Ltd

15. MD India Healthcare (TPA) Services (Pvt.) Ltd.

16. Medi Assist India TPA Pvt. Ltd.

17. Medicare TPA Services (I) Pvt. Ltd

18. Med Save Health Care TPA Ltd

19. Paramount Health Services (TPA) Pvt. Ltd.

20. Park Mediclaim TPA Private Ltd

21. Raksha TPA Pvt. Ltd

22. Rothshield Healthcare (TPA) Services Limited

23. Safeway TPA Services Pvt. Ltd

24. Spurthi Meditech TPA Solutions Pvt. Ltd

25. Sri Gokulam Health Services TPA (P) Ltd

26. TTK Healthcare TPA Private Limited

27. United Healthcare Parekh TPA Pvt. Ltd

28. Universal Medi-Aid Services Ltd

29. Vipul Med Corp TPA. Pvt. Ltd

 

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