Health alerts don't have a ringtone. They strike unexpectedly. Sounds too scary, right? Health emergencies leave people around us strained with unexpected expenses, paperwork in the hospital, delayed medical aid, and whatnot. Health insurance plans take care of your expenses, but the formalities in the hospital can make one go wild. That is where the Third Party Administrator (TPA) in health insurance comes into play.
Let's delve deeper into the blog to learn what is an insurance TPA and comprehend the role TPAs play in the healthcare domain.
What is a Third-Party Administrator (TPA) in Health Insurance?
Third-party administrator (TPA) is the connecting dot between you as a policyholder and the insurance company from which you have taken the healthcare plan. A TPA is a company registered with the Insurance Regulatory and Development Authority of India (IRDAI) and engaged by insurers. Thus, TPA is an external party that deals on behalf of your health insurance company with policy claims and customer support. Insurance companies also offer in-house claim settlement teams with a shorter turnaround time. External TPAs are dependent on the insurance company for claim settlement. TPAs are chosen by insurers; you can cancel or switch to another TPA if the insurer approves it; however, you will have to give a valid reason explaining why you want to do so.
What is the Role of TPA in Health Insurance?
Now that you know the insurance TPA’s meaning, let’s dig deeper and understand what exactly is a TPA’s role. The third-party administrator (TPA) plays a crucial role in the claim settlement process and in providing services to the insured. It includes the following:
- Seamless hospitalisation services
Inform your TPA of the prevailing situation if you are hospitalised in an emergency and need to claim on your health insurance plan. The TPA will coordinate between the hospital and the insurance company for cashless claim settlement or reimbursement.
- Cashless claim settlement
When you get admitted to an in-network hospital of your insurance provider, you must notify the TPA immediately if it is a medical emergency. If it is a planned procedure, you must notify the TPA 2-3 days in advance. Upon verification, the TPA will give pre-authorised approval for cashless treatment on behalf of the insurer. At the time of discharge, the hospital shares the bills with TPA. After the examination of the bills, the TPA facilitates payment.
TPAs issue a health card to policyholders. It is a document showing the policy details required when processing claims.
A TPA is your archive. It keeps all the essential records needed to manage and verify claims.
- Grievance redressal services
Policyholders can raise their queries through the dedicated TPA platform.
TPAs offer additional services such as arranging for an ambulance, medicines, and extra beds in the hospital.
How Does TPA Benefit Policyholders?
By now, you must be aware of the meaning of TPA in insurance. Let's see what benefits TPA has to offer policyholders. Out of the multiple benefits of TPA, the significant ones include the following:
- TPA stays in contact with a network of hospitals with a panel of experienced doctors. When a medical emergency occurs, the TPA is notified.
- Smooth and efficient reimbursement claim settlement process
- TPAs serve as nodal points of contact with the insurance company.
- A TPA provides seamless customer service to policyholders on behalf of the insurance company.
- TPAs provide all the required information about health insurance plans, including any recent changes to the policy, the validation of claims, queries regarding the sum insured sum, and much more.
- A TPA simplifies the entire claim settlement process and guides policyholders through every step.
- TPAs provide 24X7 customer support.
- TPAs provide ID cards to policyholders and assist with the documentation.
TPAs provide back-end support to insurers and help facilitate claim settlement. Policyholders can contact TPAs to resolve all queries related to their healthcare plans, ensuring improved quality of services and quicker resolution of issues.
Conclusion
Knowing what is TPA in health insurance helps you gain a clear understanding of their operational services. TPAs serve as an intermediary between insurers and policyholders and help with the hassle-free settlement of claims.
Disclaimer: The information provided in this blog is for educational and informational purposes only. It may contain outdated data and information regarding the relevant industry. It is advised to verify the relevance of the data and information before taking any major steps. ICICI Lombard is not liable for any inaccuracies or consequences resulting from the use of this outdated information.