Understanding Third Party Administrator in Health Insurance
Dec 24, 2021

Relevance of Third-party Administrator in Health Insurance Policy

In the last couple of years, one thing that most of us have realized is that a medical emergency can occur at any point in time. The ongoing global crisis has affected us both emotionally and financially. People have also understood the importance to have a health insurance policy. The treatment costs and medical inflation can easily take a toll on the finances. In tough times, having the right type of health insurance policy acts as the shield. With a plethora of health insurance companies available, choose the plan that best suits your needs. There are insurance companies that have third party administrators who help to settle the claims. Often, we discuss choosing the right types of health insurance in place. In this article, we will briefly discuss third-party administrators also referred to as third-party intermediaries.

What is Third party in Health Insurance?

In simple words, a third-party administrator is defined as the company that is registered with the authority. It is engaged by the insurance company for a certain fee. It could be referred to by another name and mentioned in the agreement of health services. The TPA functions as the intermediary between the insurance company and the policyholder. The prime function of the TPA is to effectively process the claims and settle them. A third-party administrator might render service to the insurance company within the agreement that is connected with the business of health insurance.

Role of Third party Administrator in Health Insurance

The third-party administrator has an indispensable role when it comes to completing the processing of the health insurance claim. When it comes to the health insurance section, let us understand the roles a TPA has:

Smooth Processing of Claims and Settlement

The TPA’s essentially functions between the insurance company and the policyholder. The prime function of the TPA is to process claims and settlements. The role of a TPA is to check the documents carefully. The documents are submitted by the policyholder. If not convinced, the TPA can thoroughly ask for questions and every related important information. The claims can be either cashless or reimbursement. In the case of cashless hospitalization services, the TPA can easily collect the documents directly from the hospital. In case of reimbursement, the TPA will ask for all the supporting bills and documents from the policyholder.

Issuing Health Cards/ecards to the Policyholder or Nominee

For each policy that third-party administrator issues to the policyholder, a validation for the same is required. This process is completed by issuing the health card or the ecards. These cards have the details of the policyholder, nominee, policy number, and the TPA accountable for processing the claim.   At the time of admission to the hospital, this card needs to be shown at the hospital insurance desk. Ensure intimation of the same to the insurer or TPA for a seamless process.

Provide Relevant Helpline Numbers In Case of Emergency

The policyholder should have every access to information in regards to the claims. One of the key roles for a TPA is to set up helplines that the policyholder can easily reach out to. It could be via email as well.

List of Network Hospitals

The third-party administrator has the list of all the network hospitals. On an ongoing basis, they further also try to enlist more hospitals in PAN India. They need to look for hospitals that can arrange for cashless services at cost-effective rates that benefit the policyholder.

Over to You

A third party administrator is central to the policyholder, hospital, and insurer to work in tandem. A TPA surely makes the lives of the insurers, policyholders, and hospitals easy. Before you enroll in a TPA to process the claim do a background check. Read the terms and conditions mentioned in the health insurance documents.  

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