While going through a medical insurance policy, we often come across terms, especially abbreviations; that make no sense to us. Either we skip it, or some curious souls probe in to understand the exact meaning. One such term we intend to discuss in this article is TPA. TPA or Third Party Administration is described as ‘any company who has obtained license from IRDA to Practice as Third Party Administrator and is appointed by the company.’ The description could confuse a reader, so let’s elaborate it a little. A TPA is like a BPO, it is a common point of contact between the Insurance Company and the Customer. The insurance companies can sometimes be overloaded with claims processing and could find it a repetitive and standardized activity. Hence, they outsource some of this administrative task to TPAs to ensure smooth claim settlements.
Some of the medical insurance services that TPAs play a major role in are –
Cashless Service
One of the most important functions that TPA play a major role in includes cashless service. In case you are hospitalized in any hospital listed under the medical insurance policy, the cashless service directly settles the bill up to the limit of your policy. To avail the service you need to inform this to the hospital. In that case, they would get in touch with the TPA of your insurance provider to get the approval for direct bill settlement.
Claim Settlement
They also are majorly concerned with the claims settlement process. They are in charge of taking complete intimations of claims, guiding customers on network hospitals, approving cashless and reimbursement claims and paying the claims to the customer.
Maintaining Database
Medical insurance companies pass all the records to the TPAs after the policy has been issued. From there on, they are responsible for all further communication with the Policyholders. The TPAs need to maintain the database of the policy holder, issue them identity cards with unique identification numbers, make sure the policy holder has received the ID cards within 30 days and have it ready in case of any emergency. Policyholders should know the name of their TPA and the contact number as they are the only point of contact they have in case of an emergency.
Toll Free number
The toll free number that is mentioned on the policy documents is basically the number of the TPAs who run a 24×7 service to be accessible to policyholders constantly. They will attend to your claims all round the clock and also have full-time medical practitioners under their employment to immediately take decision on whether the illness is covered under the policy.
Value added service
TPAs are also responsible for providing additional service to the insured like arranging for ambulance, medicines and supplies, offering information on 24- hour help lines, health facilities, bed availability and guiding policy holders for specialized consultation. Apart from services included in the medical insurance policy, they also provide information on organizations for lifestyle management and well- being programs.
Some of the medical insurance services that TPAs play a major role in are –
Cashless Service
One of the most important functions that TPA play a major role in includes cashless service. In case you are hospitalized in any hospital listed under the medical insurance policy, the cashless service directly settles the bill up to the limit of your policy. To avail the service you need to inform this to the hospital. In that case, they would get in touch with the TPA of your insurance provider to get the approval for direct bill settlement.
Claim Settlement
They also are majorly concerned with the claims settlement process. They are in charge of taking complete intimations of claims, guiding customers on network hospitals, approving cashless and reimbursement claims and paying the claims to the customer.
Maintaining Database
Medical insurance companies pass all the records to the TPAs after the policy has been issued. From there on, they are responsible for all further communication with the Policyholders. The TPAs need to maintain the database of the policy holder, issue them identity cards with unique identification numbers, make sure the policy holder has received the ID cards within 30 days and have it ready in case of any emergency. Policyholders should know the name of their TPA and the contact number as they are the only point of contact they have in case of an emergency.
Toll Free number
The toll free number that is mentioned on the policy documents is basically the number of the TPAs who run a 24×7 service to be accessible to policyholders constantly. They will attend to your claims all round the clock and also have full-time medical practitioners under their employment to immediately take decision on whether the illness is covered under the policy.
Value added service
TPAs are also responsible for providing additional service to the insured like arranging for ambulance, medicines and supplies, offering information on 24- hour help lines, health facilities, bed availability and guiding policy holders for specialized consultation. Apart from services included in the medical insurance policy, they also provide information on organizations for lifestyle management and well- being programs.