FAQ on Health Insurance Third Party Adminstrator (TPA)

3. What are the facilities offered by a TPA?

4. What do you mean by Network /Non-network Hospitalization?

5. What is Cashless access/Cashless Facility?

7. What documents should one obtain before discharge from the hospital in case of cash less facility availed?

8. What documents are needed for processing claims if the treatment has been done in a non-network hospital or in a network hospital where cash less facility was not granted / availed?

9. When will my claim be reimbursed?

10. Can I get Cash less facility / Reimbursement in the case of pre-existing diseases?

11. Can I get Cash less facility / Reimbursement within 30 days of policy commencement?

12. How do I get a list of network hospitals of TPA?

13. During the course of my treatment, can I change the hospitals?

14. Can I get outpatient treatment using my TPA Card?

15. I am not keen to avail of Cash less facility. Can I go in for reimbursement?

16. What is the benefit of carrying a health card?

1. What is a TPA?

Third Party Administration (TPA) is a service given to a Mediclaim policyholder by providing cashless facility for all hospitalizations that come under the scope of his/her Mediclaim policy.

2. What are the benefits of TPA to a policyholder?

The policy holder will have full freedom to choose the hospitals from the respective TPA’s empanelled network and utilize the services as per his choice • For every hospitalization, the policyholder will be well aware whether the treatment he is to undergo is covered under his policy or not. If covered, then he can seek cashless facility at any of the respective TPA’s Network hospitals. • During the time of Emergency Hospitalization, the policyholder or relative can flash the Photo ID Card of the policyholder and gain admission into any of the network hospitals. No amount is to be paid at the time of discharge too. Thus, the Individual does not have to run around for arranging cash to pay for the hospital expenses. Also TPAs have ambulance referral, surgeon's referral and specialist's referral.

3. What are the facilities offered by a TPA?

1 A 24 X 7 assistance to all policy holders through toll free number of the TPA

2 Online assistance during hospitalization and filing of claim documents

3 Assistance in providing Ambulance Services during Emergency 3 Enrollment Card against your policy, which would give you access to TPA services.

4 Cash Less service facilitation at network hospitals up to limit authorized by Mediclaim / Hospitalization Insurance

5 Claims Processing and Reimbursement for non-network hospitals

6 Other services as defined by your Employer / Insurer

4. What do you mean by Network /Non-network Hospitalization?

A Hospital, which has an agreement with aTPA for providing Cashless treatment, is referred to as a 'Network Hospital'. Cashless facility is provided ONLY at the network hospitals. Non-network hospitals are those who have not agreed to the TPA terms and conditions and any policyholder seeking treatment in these hospitals will have to pay for the treatment and later claim as per normal procedure.

5. What is Cashless access/Cashless Facility?

This means you can walk into any of the network hospitals across the country and get treated without having to pay for your bills first and then claim from the company. If you do not get admitted to a networked hospital, your expenses will be reimbursed on receipt of complete documents from you.

6. How do I avail of Cashless Facility?

Cash Less facility is available only in network hospitals. In case the patient wants to be referred to a network hospital the TPA needs to obtain the following documents from the patient before issuing a preadmission authorization for cash less facility:

1. Original first prescription of the doctor referring the hospitalization, complete with details of symptoms and diagnosis on his/her prescription letter head.

2. Hospitalization Form in the given format

3. Details of previous policies : if the details are not already available with TPA except in case of accidents

In case information is not complete in the hospitalization form or if the history of the disease is not confirmed, a preadmission authorization cannot be issued for cash less facility. In such a case, if the patient is admitted in a network hospital, treatment will be same as in the case of a non-network hospital.

The doctor must mention in the history sheet - the record of history of the disease, relation to preexisting diseases like hypertension, diabetes etc if any and history of the same.

7. What documents should one obtain before discharge from the hospital in case of cash less facility availed?

All bills in original and a discharge certificate are to be left with the hospital providing cashless treatment. The patient has to countersign all bills and fill the claim form and also leave the same with the hospital at the time of discharge. A copy of the bills & Discharge Summary can be carried by the patient for his records and for submission along with Pre & Post Hospitalization bills.

8. What documents are needed for processing claims if the treatment has been done in a non-network hospital or in a network hospital where cash less facility was not granted / availed?

Following documents are required for processing the claims on reimbursement basis:

1. Claim Form properly filled and signed by the claimant

2. Discharge Certificate from the hospital

3. All documents pertaining to the illness starting from the date it was first detected

i. Bills, Receipts

ii. Cash Memos from hospital supported by proper prescription

iii. Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying
such diagnostics. Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt

iv. Attending doctor's / consultant's / specialist's / anesthetist's bill and receipt, and certificate regarding diagnosis

v. Certificate from the attending medical practitioner / surgeon that the patient is fully cured

b. Details of previous policies : if the details are not already with TPA except in the case of accidents

9. When will my claim be reimbursed?

The claim will be reimbursed after receipt of complete documentation from the client.

10. Can I get Cash less facility / Reimbursement in the case of pre-existing diseases?

Pre-Existing diseases are excluded in Mediclaim Policy. TPA’s doctor panel will verify / check the inception of disease based on your medical records and in case the disease has an origin before the inception of the policy, then your claim is not payable, as per the policy.

11. Can I get Cash less facility / Reimbursement within 30 days of policy commencement?

Mediclaim policies have a waiting period of 30 days. Only accidents if occurred during the first 30 days of the policy are covered. Any other disease is not payable.

12. How do I get a list of network hospitals of TPA?

Along with your ID card, you will get a kit comprising of a Guide Book and List of Network Hospitals. You can also download the list from the respective TPA’s website.

13. During the course of my treatment, can I change the hospitals?

Yes it is possible to shift to another hospital for reasons of requirement of better medical procedure. However, this will be evaluated by the TPA on the merits of the case and as per policy terms and conditions.

14. Can I get outpatient treatment using my TPA Card?

No. The TPA Card is issued to you against your mediclaim policy which only covers hospitalization expenses. The outpatient / domiciliary expenses pertaining to the treatment of disease which is the cause of hospitalization is however covered (Please see Pre & Post Hospitalization benefits)

15. I am not keen to avail of Cash less facility. Can I go in for reimbursement?

Yes. Under the Mediclaim Policy, you can opt for Cash Less as well as Reimbursement. We would advise that in case you are taking treatment from a network hospital, then you should avail of the Cash less facility. This will give you the financial advantage of not paying for your hospital treatment and also gives you more cushion to meet your post-hospitalization expenses.

16. What is the benefit of carrying a health card?

The benefit of carrying the Health Card is that you and your family members get access to the cash less facility from the TPA’s network of hospitals. This means you can walk into any of the networked hospitals across the country and get treated without having to pay for your bills first and then claim form us. If you do not get admitted to a networked hospital, your expenses will be reimbursed within 7 days of receipt of complete documents from you. Also in the event of any unforeseen accident a third party can identify your Insurance Company and your family can be intimated.

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FAQ on Health Insurance Third Party Administrator (TPA)

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