CARES Act to respond to emergency health issues

Health insurance has become one of the basic aspects of life. Millions of people every day are buying insurance plans for either themselves or their families. And when it comes to claiming your insured amount, there are two ways you can do so: through the insuring company’s claim processing department or Third Party Administrators (TPA).

TPA is an essential entity that plays the role of an intermediary body between health insurers and the insurance company. IRDA has licensed TPA to process health insurance claims. Third-Party Administrator or TPA in health insurance is an important aspect that needs to be understood before you can make your claim. They are authorized to only process claims and not accept or reject them.

TPA in health insurance is a unique feature as most other insurance such as home insurance or life insurance do not come with it. The role of TPA is to facilitate the settlement between both parties (insurance company and the insured).

What is TPA?

A TPA in health insurance can be explained by calling it a middle man who settles health insurance claims. The insurer appoints the TPA and they, in turn, help you process your claims using appropriate documents such as reports and hospital bills. As soon as your claim process begins, you must contact the respective TPA and they will help you until the last claim is settled.

Many insurance companies have a tie-up with TPA companies. There are about 26 such companies that work as TPA in health insurance claims settlement.

TPA helps you get your medical insurance claim hassle-free.

The Role of TPA

The role of TPA is to handle various important aspects of insurance as given below

  • It aspects intimation, approving and disbursing the claims
  • Utilization reviews
  • Enrolment
  • Provide network
  • Cashless processing
  • Premium collection
  • Database maintenance
  • Other added services such as ambulance, specialized consultation, availability of beds, medicine supplies, health facilities, etc.

Now let us look at some of the major aspects in detail.

Issuing Health Cards

Every time a policyholder issues a policy, a validation process is carried. It is done by issuing an authorized health card. This card carries all the important details such as your policy number, validity date, etc.

TPA in health insurance approves your claims based on this card when you are admitted to the hospital. Patients can skip the complicated form filling and other bureaucratic formalities in the hospital and simply present their card to get admitted.

TPAs issues health cards that work as the major document when claiming insurance.

Smooth Claim Settlement

TPA expedites claims that are initiated by the insured. They quickly check documents in favor of the claim which speeds up the process significantly. The settlement will either be on a reimbursement basis or cashless. The TPA is entitled to ask for all sorts of documents that would enable them to understand and check through your claim. In case of cashless settlement, they can ask for the hospital documents and in the case of reimbursement, they might want the papers and bills from the policyholder.

Helpline Facility

Most TPA in health insurance also helps policyholders in accessing information and other assistance. One can call to claim their policy at any time of the day. Thus 24×7 customer service is a great relief for patients all over the country.

You can get all your answers simply through a phone call. It works great for old people who live alone and wish to be informed about their policy.

Increased Hospital Network

Earlier when insurance companies worked without TPAs, they could hardly manage the hospital network. With an overwhelming number of people claiming insurance and the complexity of hospital networks, companies found it extremely difficult to manage such a huge number of insured people and their needs. But TPA in health insurance has changed the scenario completely by taking away the pressure of managing the hospital network from the company’s shoulder. This way companies can restrict their workload to verifying claims while the processing part can be handled by the TPAs.

Database Maintenance

Whenever a policyholder needs his medical insurance, he takes help from the respective TPA. No policyholder can go unnoticed by the TPA. Thus, a TPA in health insurance has a track of all the patients who have claimed their insured money. They coordinate with the hospitals and help the patients get their claims settled. All such activities are noted and recorded in a database that keeps track of insurances claimed and the ones that have not been claimed.

Value-Added Services

Besides the major function, TPAs also provide some value-added services such as well-being programs, ambulance facilities, medicine supplies, health facilities, lifestyle management, etc.

What Documents Do You Need to Avail TPA Services?

Getting assistance from a TPA is very easy if you have medical insurance. Since they handle all the claim settling activities, you shall always find them trying to help you. However, you must have your hospitalization form, doctor’s prescription, and policy documents, or your policyholder’s card to get their services.

Advantages of Having TPAs to Deal with Claim Settlement

There are several advantages of including a TPA in Health Insurance processes. Let us briefly look at these:

  • TPAs have a tremendous hospital network which is mostly much larger than an in-house settlement department will ever have. They work towards building a web of networks to facilitate the workings. They also provide extensive coverage throughout the country.
  • TPAs manage policyholders’ claims and have streamlined processes for them. They can manage claims much better than in-house departments.
  • They keep themselves open to customer inquiry which helps in understanding and providing better services.
  • They maintain an extensive database of insurance history and which patients claimed theirs.

TPA makes claiming your insurance extremely easy. All you need to do is contact the TPA and they will help you get your settlement. Make sure that you have all the legitimate documents that you need. Gone are the days of harassment when policyholders had to keep nagging the company for claims. Since a company manages a lot of things, clearing claims becomes troublesome but a TPA in health insurance is dedicated to that function alone which makes claiming insurance much easier for people.

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