CIRCULAR NO.IRDAI/TPA/REG/CIR/059/03/2016, DATED 28-3-2016

IRDAI (THIRTY PARTY ADMINISTRATORS-HEALTH SERVICES) REGULATIONS, 2016

CIRCULAR NO.IRDAI/TPA/REG/CIR/059/03/2016DATED 28-3-2016
[AS AMENDED BY CIRCULAR NO.IRDAI/HLT/REG/CIR/015/02/2018, DATED 2-2-2018]

1. OBJECTIVE

I RDM (TPA – Health Services) Regulations, 2016 were notified on 14-03-2016. Vide various provisions of the said regulations the Authority has to specify the Regulatory Norms, Forms, Formats, and Check list etc., for compliance by all TPAs and other regulated entity, if applicable.

The objective of this circular is to set out regulatory requirements that a concerned applicant or registered entity, as the case may be, shall comply with.

2. APPLICABILITY

This circular is applicable to all applicant TPAs, registered TPAs and the insurers wherever applicable.

3. LEGAL AND OTHER PROVISIONS

3.1 This circular is issued under the provisions of Section 34 (1) of Insurance Act, 1938 and under the powers vested with Reg. 2 (1) (I) of IRDAI (TPA – Health Services) Regulations, 2016.

3.2 “Key Managerial Person referred in this circular includes the Chief Executive Officer, Chief Administrative Officer, Chief Operating Officer, Chief Finance Officer or Chief Accounts Officer and Chief Medical Officer.”

3.3 In this circular where name and details of CEO or CAO are sought in case both these officers are in existence details of both officials shall be submitted.

3.4 Where shareholders are referred in these forms information shall be submitted in respect of those shareholders who are having 5% and above stake in the TPA Company.

3.5 The periodicity of the reports shall be as mentioned under respective annexure in this circular.

4. Standard Pre-Authorization And Claims Forms;

The Insurers, TPAs and Network Providers, as the case may be shall use the following forms specified at Annexure – 30, while rendering health services;

4.1 Claims Form Part – A: Claim Form Is Applicable For Health Insurance Policies Other Than Travel And Personal Accident Policies.

4.2 Claim Form Part – B: Claim Form To Be Filled In by the Hospital

4.3 Pre-Authorization Form Part – C: Request for Cashless Hospitalization for Health Insurance Policy.

5. Effective date:

The provisions of this circular shall be applicable with immediate effect or as specified in the respective provisions of this circular.

Annexure – 1

 

Annexure – 2

 

Annexure – 3

 

Annexure – 4

 

Annexure – 5

 

Annexure – 6

 

Annexure – 7

 

Annexure – 8

 

Annexure – 9

 

Annexure – 10

 

Annexure – 11

 

Annexure – 12

 

Annexure – 13

 

Annexure – 14

 

Annexure – 15

 

Annexure – 16

 

Annexure – 17

 

Annexure – 18

 

Annexure – 19

 

Annexure – 20

 

Annexure – 21

 

Annexure – 22

 

Annexure – 23

1 [Annexure – 24

As per Regulations 22 (4) of IRDAI (TPA – Health Services) Regulations, 2016

Non Insurance Services under Health Care Schemes

1. A TPA may render Health Services to health care schemes promoted, sponsored or approved by Central Government or any State Government

Explanation :No Public Sector Undertaking shall come within the ambit of the above clause.

2. A TPA may render services in wellness and Health promoting programmes, only if such activities are covered under insurance policy as issued by the concerned insurer, with whom a TPA has agreement for rendering of Health Services.

Provided that TPA shall not render any services directly or indirectly to the policy holder or insured, except such health services that are required to be rendered as per agreement with the insurer and within the terms of the concerned policy contract.]

Annexure – 25

 

Annexure – 26

 

Annexure – 27

 

Annexure – 28

 

Annexure – 29

 

Annexure – 30

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