How Does TPA Help During Claim Processing In Health Insurance?

A whole range of Health Insurance benefits are available out there. In this article, we will tell you how does TPA help during claim processing in health insurance?

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How does TPA help during claim processing in health insurance?

TPA is the abbreviation for Third-party Administrator. This person/organization is not directly involved in a health insurance policy contract i.e., not the first or second party. The TPA is involved with administrative services mentioned in the health insurance contract.

How does a TPA help me with my health insurance policy?

A health insurance policy is much more complicated as compared to other general insurance plans such as motor insurance policy. This is because a health insurance policy involves a lot of terminologies. Hence, it is quite natural for many policyholders to find difficulties in understanding the exact terms of their health insurance policies.

But learning all about a health insurance policy does not have to be necessarily confusing. Rather than looking at an overview of the entire policy, it would be much easier to take a look at one component at a time. As we all know, there are many policyholders who feel out-of-bounds when they have to settle claims. This is where a TPA comes in. A TPA is the third-party in the health insurance agreement responsible for administering the claim settlement process of the contract which is between you and the insurance company.

In short, the TPA is:

  • Chosen by the insurance company
  • Associated with the insurance company to ensure a smooth claims settlement procedure
  • A link between you and the insurance company in case of a hospitalization claim
  • Responsible for facilitating the claim settlement process by looking over the management of documents and hospital bills
  • Allowed to be associated with numerous health insurance companies in India
  • Licensed by the Insurance Regulatory and Development Authority of India (IRDAI)

Let us take a look at a deeper look into the role of a TPA in health insurance:

1. Co-ordinating claim settlements:

A TPA is a very important part of the claim settlement process. The communication between an insurance company and the hospital is integral, especially when the insurance company provides cashless services to their policyholders and settle their healthcare service bills directly with the hospital. The TPA provides back-end support on both sides to ensure smooth and effective communication.

2. Maintaining records

When a policyholder is admitted to a hospital, they need to have all their documents in place in order to make claims through their health insurance policy. A TPA could be of great help in this aspect since they are tasked with maintaining all the crucial records in an organized database for the insurance company.

3. Connecting link

When the policyholder needs to file a claim, they will directly or indirectly meet with the TPA, who will provide them an ID card and Unique Identification Number for the claim settlement. This is where the TPA acts as the link between the policyholder and the insurance company.

4. Checking set criteria for hospitals

A TPA also performs a duty termed as ‘Hospital empanelment’ where they verify whether the hospital meets all the required criteria for being an insurance company’s network hospital providing cashless services to policyholders.

We hope that this article has helped you understand the role of a TPA in processing claims in a health insurance policy. All the best!


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