Page 267 - IC38 GENERAL INSURANCE

E. Billing services

Under billing services, the insurer expects the TPA to provide three functions:

a) Standardized billing pattern that can help the insurer analyze the use of
coverage under various heads as well as decide the pricing.

b) Confirmation that the amount charged is relevant to the treatment
really required for the illness.

c) Diagnosis and procedure codes are captured so that standardization of
data is possible across all TPAs in accordance with national or
international standards.

This requires trained and skilled manpower in the TPA who are capable of
coding, verifying the tariff and standardizing the billing data capture.

F. Claim processing and payment services

This is the most critical service offered by the TPAs. Claim processing services
offered by the TPA to the insurer is usually end-to-end service from registering
intimation to processing to recommending approval and payment.

Payment of claims is done through the funds received from the insurer. The
funds may be provided to the TPA in the form of advance money or may be
settled directly by the insurer through its bank to the customer or to the
hospital.

The TPA is expected to keep an account of the monies and provide periodic
reconciliation of the amounts received from the insurance company. The
money cannot be used for any other purpose except for payment of approved
claims.

G. Management Information Services

Since the TPA performs claim processing, all information relating to the claims
individually or collectively is available with the TPA. The insurer requires the
data for various purposes and such data must be provided accurately and on a
timely basis by the TPA.

Thus the scope of a TPA‟s services can be stated as end-to-end service of the
health insurance policies issued by the insurers, could be restricted to few
activities, depending on requirements and MOU with particular insurer.

H. TPA Remuneration

For these services, the TPA is paid a fee on one of the following basis:

a) A percentage of the premium (excluding service tax) charged to the
customer,
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