What Is TPA In Health Insurance? How Does It Work?

Health Insurance

A third-party administrator (TPA long-form) is an administrative body in charge of processing insurance policy claims. However, the said claims have to be admissible under a mediclaim policy. Typically, administrators are treated as independent bodies, but they also hold power to serve as an entity to insurers. 

The Insurance Regulatory and Development Authority (IRDA) came up with TPAs to extend the quality and consistent services to the public and simplify the claim process. However, since individuals can choose a TPA while buying a health insurance policy, they must check the updated TPA hospital list to begin their investigation. 

List of top TPA’s 

Finding out the medicare TPA network hospitals list is not enough. Individuals should also check the list of hospitals involved with each of these TPAs to avail timely help. 

Also Read – https://navi.com/blog/tpa-third-party-administrator/ 

Benefits of TPA

Typically, TPA is concerned with issuing health cards to insured entities. These administrators are also involved with streamlining processing and claim settlement.

Furthermore, TPAs help build a robust network of hospitals from where policyholders can avail the best quality treatment. Generally, TPAs strive to enlist the top hospitals to help arrange cashless treatment and extend quality service at negotiable rates. 

Hence, from policyholders’ perspective, TPAs serve as an intermediary between them and their insurance provider. Additionally, they help to settle cashless and reimbursement claims without any hassles. 

Besides, as per industry experts and observes, the following are the benefits of TPAs:

• Delivery of efficient and greater quality of service
• A strengthened knowledge base of the healthcare industry and services
• Accelerated penetration of the health insurance industry
• Efficient protocols to avoid unnecessary delays and to streamline the process

Since a lot depends on policyholders’ TPA when it comes to settling an insurance claim, one must be cautious when selecting an administrator from the updated TPA hospital list.

Also Read – https://navi.com/blog/network-hospitals/ 

How to Select the Right TPA for Insurance Policy Claim Settlement?

Selecting a suitable third-party administrator from the insurance TPA list ensures a smooth claim process. Keep these pointers in mind to select the right kind of TPA to settle your health insurance policy claims:

Check the list of TPA network hospitals 

First, find out which hospitals are near you and which of them would you prefer the most to seek treatment. Subsequently, find out which of them are included in the list of network hospitals of most health insurance policies. 

Find out the TPAs handling the insurance claims of hospitals located near you

Make inquiries to find out which TPAs are engaged with the best of network hospitals. Also, find out about their claim settlement track record, if possible. 

Compare the health care services extended by TPAs

Check the portfolio of services offered by those third-party administrators. Do not forget to find out about additional offerings, such as value-added services extended by the TPA. Note that such services may include health care facilities during emergencies and even wellness programmes. 

However, if you have already chosen a health insurance provider, you can simply find out which TPAs are engaged in their claim settlement process. 

Subsequently, find out their offerings and track of settlement for a better idea. For example, Navi Health insurance works closely with Raksha Health Insurance TPA Private Limited, Paramount Health Services and Insurance TPA Private Limited, and Family Health Plan Insurance TPA Limited to process insurance policy claims. 

Exclusions under TPAs: At a Glance

IRDAI and TPA regulations have standardised multiple definitions and formats in the health insurance sector to improve the functioning and quality of service provided by them. The two regulating bodies have also listed standardised exclusions in health insurance policies keeping in mind the interest of both insurer and insured.

A few of such exclusions include:

• A 30-day waiting period will apply to all claims from the date of commencement of the insurance policy. However, that does not include cases related to injuries resulting from accidents.
• Policyholders cannot raise a claim in case of pre-existing diseases.
• Congenital illness or condition.
• Expenses resulting from self-inflicted injuries, venereal diseases, HIV, AIDS, substance abuse, etc.
• Treatment resulting from pregnancy or pregnancy-related complications.
• Domiciliary treatment.
• Treatment availed from outside TPA network hospital list.
• Expenses incurred when hospitalised but categorised as non-medical.
• Age-Related Macular Degeneration.
• Disorders related to puberty or menopause.
• Treatment of psychological disorders, stress, or mental illness.

Make sure to check the complete list of exclusions from your insurance provider to make an informed choice.

Steps to File a Claim for Health Insurance Plan 

Ideally, a claim is admissible if medical practitioners have advised the policyholder to get hospitalised for at least 24 hours except for diseases like cataracts. 

Like discussed, TPA’s primary role is to simplify the health insurance claim process. Take a look at the steps below to understand how to raise a claim under health insurance policy and TPA’s role during the entire process:

Step 1

Policyholder visits a network hospital under a TPA to avail treatment.

Step 2

In case of hospitalisation of more than 24 hours, policyholder has to inform the TPA or his/her insurance provider about the same.

Step 3

The concerned TPA will prompt the hospital to extend cashless treatment, if possible. Alternatively, TPA will process the same claim for reimbursement. 

Step 4

In case cashless treatment is approved, the concerned hospital will send the invoice to TPA. However, if a claim for reimbursement was processed, then the policyholder will submit the required documents, including the invoice, to TPA later on.

Step 5

Post scrutiny, claim settlement will be allowed by the authorities at TPA. 

Step 6

If cashless treatment was offered to the policyholder, the hospital would release the payment. Alternatively, for reimbursement claims, the expenses will be sent to policyholders through the insurance provider. 

Reasons to Buy Health Insurance Plans from Navi 

Here are the top reasons why you must consider  the Navi App to buy your health insurance!

• Applicants avail health insurance policies through the Navi Health Insurance app in 90 seconds.
• Policyholders avail cashless claims in 20 minutes in more than 10,000+ network hospitals.
• The entire claim process is carried out without the involvement of any agent.
• Enjoy a minimal documentation process when raising a claim.
• The health insurance policy comes with affordable EMIs. 

The application and claim settlement terms are transparent and streamlined to help policyholders avail the best of medical assistance in their time of need.

Final Word

The proactive involvement of TPAs ensures the standardisation of procedures and the deliverance of services. In turn, they prove useful to ensure a smooth and hassle-free claim process. Regardless, individuals planning to buy a health insurance plan must check the TPA hospital list beforehand to ascertain the movement of claim proceedings and the merit of the insurance policy provider in due advance.

Frequently Asked Questions

Difference between TPA and insurance providers?

Third-party administrators serve as a service provider to every insurance company offering health insurance plans, whereas health insurance providers offer insurance products to entities. 

Does the location of a policyholder matter in availing TPA services?

Typically, the location of the policyholder does not impact the process of availing services under TPA. However, insurance providers engaged with multiple TPAs may designate certain TPA for specific locations to ensure quick claim processing.

How to send a cashless claim?

With Navi Insurance, you can raise a cashless claim readily by reaching out to our customer care services. Alternatively, you can also use our customer portal or Navi app to raise a claim.

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Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.