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The Role of TPA during Claim Processing in Health Insurance

A TPA or Third-Party Administrator is a mediator between the health insurance policyholder and the health insurance provider. The term ‘TPA’ does not refer necessarily to an individual but rather to an administrative body licensed by the IRDAI. Apart from taking on several regulatory functions, a TPA’s main domain lies in the claim processing and settlement of various policyholders. If you hold a health insurance policy, then an understanding of the role your TPA will play during claim processing is important. Let’s look at that in more detail in this article.

How does a TPA help streamline your claim processing? 

Issuing health cards

When you purchase a health insurance policy from an insurer, the insurance provider shares your policy-related information with the TPA. Based on this information, the TPA provides a health card to you. This card is an important document, as you will be required to possess it with you when you raise a claim for cashless treatment. Along with a specific health card number, this card will also have the relevant information of the TPA so that the policyholder can contact them when required.

Role of TPA during cashless claims 

If you have planned to avail cashless treatment at a network hospital before your admission, then you should inform the TPA a few days prior as well. You can cite the health card number when informing and the TPA will take notice accordingly.

During admission, you or your relative will have to fill the cashless request form correctly. The doctor assigned to your case will have to verify it before you send it across to the TPA along with the relevant medical records. The TPA scrutinizes the submitted form and records and considers the claim request. If there are any additional documents required, the TPA will convey the same to the hospital and you may have to provide them accordingly.

Post this, the TPA will decide on whether to approve your claim or not. Once approved, the payment will be settled directly by the TPA. You may have to pay for the inadmissible charges as per your health insurance policy.

Read more: Should I Increase My Health Insurance due to the Pandemic?

In case of cashless claims for emergency hospitalization, it would be considered alright if the policyholder is not able to inform the TPA beforehand.

Role of TPA during reimbursement claims

In case of a claim where the policyholder is to be reimbursed, the hospital shares the medical records and bills with the TPA, following which the TPA will verify the claim. Once approved by the TPA, the process of the reimbursement of the hospital expenses, subject to the conditions of the policy, shall begin.

The TPAs are very stringent in weeding out false claims, ensuring that only genuine claims get approved. In case a disqualified claim requires redressal, it is the TPA who will take care of it. Thus, a TPA ensures that the claim settlement process goes smoothly and effectively, for the insured as well as the insurer.

Different health insurance providers have different TPAs or sets of TPAs; ensure that you do your research on the TPA you have been allotted before going ahead with any major decisions.

We hope this article has increased your understanding of the role a TPA plays during claim processing in health insurance. Do make sure to always compare options before you buy health insurance. Good luck!

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