What's a TPA (Third Party Administrator) In Health Insurance | Pazcare
TPA in health insurance, Advantages of TPA, Role of TPA, Top TPA companies
September 21, 2022
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A group health insurance claim is a request that a health insurance policyholder (employee) submits to a health insurance company to get the services mentioned in their health plan/policy during hospitalization or medical treatments. By sending this request, the health insurer is notified to initiate the claim process.
There are two types of claims in group health insurance. They are cashless claims and reimbursement claims.
As the name suggests, it frees us from handling money during medical emergencies. In a cashless claim, the insurer settles the medical bills directly with the hospital itself. This is applicable only if the policyholder is admitted to a network hospital.
In the case of surgery, hospitalization is planned. Whenever a hospitalization is planned, the policyholder must inform the TPA or network hospital at least 72 hours prior.
For availing of a cashless claim for emergency hospitalization, you will have to inform the insurer or TPA within 24 hours of hospitalization.
In a reimbursement claim, once the insured is admitted to a hospital, the bills are paid from your pockets. Later, the insurance company will reimburse the claim amount to you once you provide the necessary documentation.
This is mostly the case when the policyholder goes to a hospital that is not in the network hospital list of the insurer. However, the claims are settled by evaluating the credibility of the documents you provide.
This is why it is important to choose an insurer with an extensive hospital network and a high claim settlement ratio. A claim settlement ratio suggests the percentage of claims settled by the insurance company to the policyholders in a financial year. The higher the ratio, the higher the chance of your claims being settled.
The claim process might vary depending on your insurer. Below is the common claims process for cashless.
The process remains the same for planned and emergency hospitalization. However, the claim intimation must be done within the time limit mentioned above.
The reimbursement claims can be initiated in a hospital of your choice. The general procedure includes
Claim intimation is informing your insurer or TPA when you are going to raise a claim. This allows them to provide you with insurance services.