Role of Third Party Administrator (TPA)

What is the role of a third party administrator TPA in health insurance policies?

TPA known as Third Party Administrator & are licensed by IRDA (Insurance Regulatory & Development Authority). Each health insurance companies has some internal or external TPA.

TPA are having

  • Telecom or toll free no.
  • Computer which have details of all policies holders.
  • Medical specialists for hospitalization treatment verification being given in the hospital and passing claim bills.

The important role of TPA's are: Coordinate with hospitals for treatment undertaken by insurer & pass claims on behalf of insurance company.

The individual insured received ID card issued by the TPA. This ID Card is useful and needed at the time of hospitalization.

Communication with TPA:

In an emergency, the insured can be taken for treatment in any hospital to save his/ her life. But need to inform about hospitalization to Insurance Company and TPA on phone as well as in writing about the following:

  • Name of Insured Patient
  • Policy No.
  • TPA ID Card.
  • Doctors recommendation letter for hospitalization

If needed further treatment required patient can be moved to TPA approved hospital.

TPA may ask to make the payment to hospital where patient was taken in emergency and submit the bills for reimbursement if hospital is not in approved list. If after few days patient is moved to TPA approved hospital then bill of that hospital will be paid by TPA directly.