Third-Party Administrator (TPA) in Health Insurance

A TPA in health insurance stands for Third-Party Administrator. It is an entity that manages and administers health insurance policies on behalf of insurance providers. The primary role of TPAs is that they make the process of claiming health insurance easier. 

This way, you do not need to stress about managing the claim process in the case of medical emergencies. On Bajaj Markets, get a health insurance plan with affordable premiums and file your claims hassle-free.

TPAs act as intermediaries between you and the insurance company. It provides assistance in claiming benefits and managing insurance claims. When you get admitted to a network hospital, in the case of a cashless facility, the hospital will send the treatment details to TPA.

 

After TPA verifies your eligibility and coverage of the policy, it issues a pre-authorisation to the hospital. You can get your treatment without having to pay any upfront costs. However, know that this is applicable only if you meet the required eligibility parameters and other details.

 

Likewise, when you opt for services at non-network hospitals, you have to make upfront payments at the time of discharge. Once you submit original documents, such as your receipts, medical bills, and other paperwork, the TPA forwards the same to the insurer.

 

Once the insurance company approves your claim, TPA credits the amount to your bank account. Remember, TPA scrutinises all your documents thoroughly before sending them to the insurer. 

Third-party administrators in medical insurance offer numerous benefits. Here are some of the advantages you need to know about:

• Seamless Insurance Claims

You can claim insurance benefits conveniently with the help of TPAs, who efficiently save you time and effort

• Support to Policyholders

TPAs guide you about your policy features, hospital networks, and covered medical facilities

• Cashless Hospitalisation

TPAs connect with network hospitals and insurers during cashless hospitalisation for direct payments

• Records Expenses

TPAs keep a record of all expenses related to your treatment to make the claims process seamless

TPAs play an essential role in your health insurance claim process. Here are some of their primary roles:

• Facilitates Bill Settlements

TPAs help in direct bill payments by coordinating between insurance companies and hospitals

• Serves as a Connecting Link

TPAs act as an intermediary between you and the insurer to make the health insurance claim process streamlined

• Provides Customer Support

Many TPAs offer support via call centres and mobile apps to ensure you can easily raise queries and get assistance quickly

• Maintains Records of Expenses

TPAs maintain essential records of your treatments, hospitalisation bills, medicine bills, and more

• Additional Services

Some TPAs offer additional services such as ambulance services, extra beds, and medicine supplies

As mentioned, the central role of TPAs is to facilitate the process of health insurance claims. Here is how they prove to be helpful:

• Adequate Guidance

TPAs guide you through a step-by-step process, making it easy for you to claim your health insurance

• Claims Filing

TPAs assist you in filing claims by ensuring you complete all requirements, such as paperwork, accurately

• Verification

After filing the claim, TPAs verify everything to ensure you receive all benefits that you are eligible for

• ID Cards and Unique Identification Numbers

TPAs issue ID cards and unique identification numbers to make cashless settlements easier

Insurance companies also have specialised departments to facilitate the claim settlement process. These are known as Health Administration Teams (HATs). Refer to the following table to understand how TPAs and insurance companies differ in this context:

You enjoy the flexibility of cancelling the services of an existing TPA. You can also switch to another TPA. Here are the steps you need to follow to cancel TPA in health insurance:

1. Contact the insurance company via phone or email

2. Provide the details of your health insurance plan and unique ID (UID)

3. Describe the reason for cancelling the TPA

4. Upon approval from the insurer, you can choose another TPA from the available TPAs