What is a TPA and what are its roles?

Over the past few years, there has been a subsequent increase in the number of insurers, policies sold, and buyers. Insurers found it difficult to keep track of work, which led to a decline in the quality of services they offered to their customers. Hence, IRDA came up with Third Party Administrators (TPA) to help in the processing of claims and to provide quality service.

What is a TPA?

A Third Party Administrator is a company that deals with operational services such as processing health insurance claim admissible under the mediclaim policies under contract to another company. Insurance companies usually outsource their claim processing to third parties.

A TPA is responsible for:

• Managing and processing a large number of health insurance claims.
• Offering high-quality and speedy services to clients.

What are the roles played by a TPA?

A TPA plays a crucial role in the processing of health insurance claims. A few of the important roles played by a TPA are:

1. Issuance of health cards to the insured A validation procedure is carried out for every policy issued to the policyholder. This procedure authorizes a health card to be issued to the insured. A Health card is required at the time of hospitalization as it contains the policyholder, the policy number, and the TPA responsible for processing claims. The insured can show this card and inform the TPA or insurer of the claim.
2. Smooth and speedy processing of claims TPA's essential tasks include smooth and speedy processing of claims. They are responsible for speedy claim processing as soon as it is intimidated by the insured. TPA ensures a smooth claim processing settlement by verifying and checking the documents submitted by the insured. They can ask for more information as and when required. Claims could either be cashless or reimbursement. In cashless claims, TPA collects all the necessary documents directly from the hospital. The insured is asked to produce bills and other supporting documents for reimbursement claims.
3. Provides helpline facilities for customer query The policyholders must access information and assistance to solve their claim-related questions. TPAs should set up helplines available 24x7 and valid all across the country so that policyholders can reach out whenever they have a query. To know the status of their claim, policyholders can call the toll-free number 1800-258-5956.
4. Strengthens and builds the hospital networks - A TPA needs to have a massive and robust network of hospitals. TPA ensures to build a strong network of hospitals by enlisting the best hospitals so that policyholders can easily avail cashless treatment with minimum hassle.
5. Arrange for extra value-added services - TPA's arrange for value-added services like ambulance services, wellbeing programs, specialized consultation, 24x7 toll-free helplines, etc. It is also the responsibility of the TPA to ensure seamless and smooth delivery of services along with sharing their knowledge about health insurance with the insured.

A TPA carries out various roles that benefit both the insurer and the insured. TPA is essential for the insurance company, hospital, and insured to work simultaneously in sync. Furthermore, different TPAs have many of their features that ease the work of the insurers, hospitals, and policyholders. Before enrolling in a TPA, remember to read the terms and conditions to set your expectations from your TPA.