Third party administrators (TPAs) are firms that provide administrative services in the health insurance field. In most cases, TPAs provide various services like claims processing, premium collection, underwriting, etc. In certain cases, they may also provide customer service on behalf of an insurance company. TPAs handle the administrative part of insurance, and they charge some fees and commissions from insurance companies for their services.
In order to function as a TPA, a company must obtain a license from the Insurance Regulatory and Development Authority of India (IRDAI). They serve as an intermediary between an insurance company and its customers. In India, TPAs are used by many public sector general insurance companies. In the private sector, some firms outsource their administrative activities to TPAs whereas some firms prefer to handle these tasks on their own.
For some companies, handling the health insurance administration could be a huge task. Every day, hundreds of customers apply for claim settlement or cashless treatment request. Without a proper administrative team, an insurer may not be able to handle these tasks effectively. A third party administrator, on the other hand, is fully equipped to deal with these tasks. Some of the key benefits of using TPAs in health insurance include:
Third party administrators are typically involved the following tasks:
One of the major tasks handled by third party administrators involves providing approval for cashless treatment requests. The insured typically contacts the TPA through the network hospital and files a cashless treatment request. Once the details are submitted, the TPA will verify the claim request and determine its validity. Upon verification, the TPA will provide the authorisation for cashless treatment. Timing is crucial when it comes to cashless treatment. A TPA must verify all the details thoroughly and provide the approval within a few hours.
Though TPAs provide a valuable service in the administration of health insurance, the process comes with its own set of challenges. Some of these challenges can be listed as follows:
There are many third party administrators operating in the Indian health insurance market. Some of top administrators in the field can be listed as follows:
Yes, as long as the hospitalisation has been made within the country, the services of the TPA can be taken from anywhere around India.
At the time of purchase of the policy, the TPA will provide a list of network hospitals. Alternatively, you can visit the official website of the TPA to find a list of network hospitals.
If you lose your ID card, inform the TPA. They will issue a duplicate ID card. Depending on the TPA, they will charge nominal fees to issue a duplicate copy.
Contact the customer care department of the TPA and inform them about the mistake on the card. In most cases, they will ask you to return the card and ask you to specify the mistake so that a new card can be issued with no mistakes. In case of any queries, you can always contact the TPA. They will guide you through the process.
To avail the cashless service in network hospitals, the insured person will have to get pre-authorisation from the TPA. The individual will have to provide information about his/her policy and treatment being availed. The TPA will verify the details and provide an authorisation letter specifying the maximum limit up to which the treatment can be covered under the policy. The rest of the expenses will have to be borne by the insured individual.
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