Things You Need To Know About Third Party Administrator Health Insurance


What is a Third Party Administrator(TPA)?

The third party administrator (TPA) is the link between the insurance company and the insured.  It is a facilitator to provide you relevant documents, claims, hospitalization details and any matter related to insurance. It is the first point of contact for the insured for any query related to the health insurance policy or claim.

Record Keeping

The policy holder’s details are maintained and updated by the health insurance TPA (Third Party Administrator)s. TPA is also responsible to issue health cards to the insured after health insurance policy is issued.

Claim Settlement Process

When you submit your hospital bills and medical test reports, it is thoroughly scrutinized by the Third Party Administrator(TPA). It has a team of doctors, accountants, legal experts, management consultants, IT professionals and  insurance sector’s experts. Your claim file passes through the experts of TPA, that  compile, verify and settle the claim of the insured. In case of any discripancy  of the documents, they ask it from the insured. The TPA has also a right to cross verify the documents or details from the hospital, test laboratory, doctors or any relevant parties.

Cashless Claim

When there is a need to raise the claim, it is processed through the TPA(Third Party Administrator) via hospital or directly from the insured. TPA is responsible to verify the details of the insured and his eligibility. The eligibility criteria includes the amount, disease covered, validity of the policy and authenticity of the claim. Once verified, the insurance company approves the cashless claim and intimates the same to the hospital. Hence, TPA facilitates smooth treatment and financial transactions for the patient and hospital both.

Appointments of Network Hospital

One of the important tasks of the health insurance TPA is to search, verify and validate the hospitals in various cities and include them in the network of the insurance company. The network hospital facilitates smooth claim processing and cashless facility. It is one of the important criteria for the customer to choose the suitable insurance company.

Customer Care Center

When you call the customer care phone number of the insurance company, it is handled through the TPA office. TPA is responsible to maintain record, reply and resolve the queries of the customers. It also gives you the status of your claim and probable date of claim settlement.

Choice of Health Insurance TPA

As per latest notification from IRDA(Insurance Regulatory and Development Authority), the customers have the choice to choose their own TPA for claim related services. The insurance company has to provide the list of available TPAs to the customers at the time of availing new health insurance policy. The similar choice has to be given at every renewal of the policy. The customer has the choice to select appropriate TPA based on his own experience with TPA or based on market information. This step is aimed to achieve the highest service level by the TPAs and to protect the right of the insured.

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