GIPSA, PPN and Empanelment in Health Insurance - Explained
GIPSA, PPN in GIPSA, Points to remember before opting GIPSA services, hospitals, empanelment
February 20, 2023
Table of contents
A third-party administrator or TPAs are bodies licensed by the Insurance Regulatory and Development Authority of India (IRDAI). These administrators are independent, but can also work as an entity belonging to the insurance company. TPA or third-party administrators also provide administrative services like health insurance claim processing, settling claims, collecting premiums, etc. Let us understand more about these third-party administrators or TPA. So, these TPAs act as a middleman between the policyholders and the insurance company.
In this case, the TPA provide services to the employees who have an active group health insurance policy from their organization.
TPA full form in insurance → Third-party administrator
In the last few years, the number of health insurance companies in India, the policies sold, types of health insurance products, and the buyers saw a rapid increase. As a result, it became very tough to offer quality services and even keep a track of these records. So, IRDAI appointed these third-party administrators to process claims and offer quality services to the policyholders.
The role of TPA in health insurance is very versatile and they are
The major function of a health insurance TPA or third-party administrator is to process and settle the group mediclaim policy and other retail insurance claims raised by the policyholders. Third-party administrators check all the documents regarding the claim and even cross verifies it. These claims can be a reimbursement claim or a cashless claim process. The TPA is liable to initiate the claim as soon as it is raised by the policyholder.
When the organizations provide medical insurance for employees, the TPA provides them with a TPA card. TPA card is an interchangeable term used for a health insurance ID card issued to the employees. It is an identity card with a unique ID number/policy number.
This card holds information like policy number and details about the TPA who will process the claim. During the time of hospitalization, the policyholder can show his/her health insurance card and raise the claim to the insurance company or the TPA. After raising it, the TPA takes care of the rest of the processes. Today, most insurers and TPAs offer e-cards to allow easy processing of cashless claims.
TPA can build an effective network of hospitals where the policyholder can avail treatments and cashless facilities. They constantly get hospitals empaneled with them and update the list of the network hospitals for policyholders’ visibility.
Another important function of the TPA is to provide services like arranging ambulance services and cashless services at the network hospitals.
Read : Network and non-network hospitals
Major advantages of the third-party administrators in health insurance are
Not all insurers work with TPA. Some insurer have in-house teams to handle the tasks of TPA. For instance, Aditya Birla group health insurance company has an internal TPA to handle the claims of the policyholders.
An in-house claim settlement department or Health Administration Team (HAT) is an entity set up within the insurance company for only its customer-centric functions. The in-house claim settlement department has the same function as that of the outsourced TPAs. The job of the inbound claim settlement department is to provide a hassle-free claim settlement experience and solve any grievances of the policyholders of the insurance company without any delay.
In-house TPA also known as Health Administration Team (HAT)
TPA in hospitals helps patients with their insurance policies. If patients want to use their insurance policy during their hospitalization, TPA can help them raise a claim. TPA is there in the hospital so you could inform prior about the hospitalization and your policy.
Third-Party Administrators (TPA) services include generating health ID cards, helping patients and insurers with documents for claims, updating claim status, and building network hospitals.
There are 19 TPAs in India. You can check all the TPAs in India here
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