Circular as per the provisions of IRDAI (TPA – Health Services)

DlldM INSURANCE REGULATORY AND ir.tai DEVELOPMENT AUTHORITY OF INDIA CIRCULAR Circular as per the provisions of IRDAI (Third Party Administrators - Health Services) Regulations, 2016, to all TPAs, Life, Non-Life and Stand alone Health Insurance Companies. _ Circular Reference No. IRDA/TPA/REG/CIR/059/03/2016, dated 28-03-2016 Issued on : 28-03-2016 m~ ~. cm:m(@, <itl/O(<i11•1, ~-soo 004. 'lfficf (() : 91-040-2338 1100, ~: 91-040-6682 3334 i-iR: irda@irda.gov.in ir-1': www.irda.gov.in Page 1 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-2338 1100, Fax: 91-040-6682 3334 E-mail : irda@irda.gov.in Web.: www.irda.gov.in Sr. Annexure No. Form No. No 1 -- -- 2 -- -- 3 -- -- 4 -- -- 5 Annexure - 1 TPA- 1 6 Annexure - 2 -- 7 Annexure - 3 TPA- 1A 8 Annexure - 4 TPA- 2 9 Annexure- 5 TPA- 3 10 Annexure - 6 TPA-4 11 Annexure - 7 TPA- 4A 12 Annexure - 8 TPA- 5 13 Annexure - 9 -- 14 Annexure - 10 TPA- 6A 15 Annexure - 11 -- 16 Annexure - 12 TPA - 7 17 Annexure - 13 -- 18 Annexure - 14 TPA- 7A 19 Annexure - 15 -- 20 Annexure - 16 TPA- 8 21 Annexure - 17 TPA- 6B 22 Annexure - 18 TPA- 6C 23 Annexure - 19 TPA- 60 24 Annexure - 20 TPA - 6E 25 Annexure - 21 -- Annexure - 21 -- 26 Annexure - 23 TPA - 6F 27 Annexure - 24 -- 28 Annexure - 25 TPA- 6G 29 Annexure - 26 TPA- 6H 30 Annexure - 27 -- 31 Annexure - 2.8 TPA - 9 32 Annexure - 29 -- 33 Annexure - 30 -- t,Ham INSURANCE REGULATORY AND inlai DEVELOPMENT AUTHORITY OF INDIA INDEX Particulars Page No. Objective 3 Applicability 3 Legal & other provisions 3 Effective Date 4 Application for Grant of Fresh Certificate of Registration to TPA 5 - 10 Check-list for Documentation to be submitted along with Form TPA - 11 1 and Procedural requirements for obtaining Fresh TPA Registration Format for Certificate of Registration 12 Declaration and Undertaking with respect to fit and proper criteria 13-16 Form for Intimation of appointment or change in Director, or Key 17 Managerial Personnel. Aoolication for issue of Duplicate Certificate of Registration. 18 Format for Duplicate Certificate of Registration 19 Application For Change In Shareholding Pattern 20- 21 List of documents to be submitted for consideration of application for 22-23 change in shareholding pattern Status of Shareholding Pattern of a TPA Company 24 Minimum Business Requirements for TPAs 25 Application for Renewal of Certificate of Registration 26-28 List of documents to be attached with the Application for Renewal of 29 TPA Registration. Format for Certificate of Renewal of TPA Registration 30 List of documents to be submitted along with application for 31 Voluntary Surrender of TPA Registration. Form for Annual Report by TPA and Schedule 1 to 7 under the.said 32- 41 form TPA-8. Format for Quarterly and Cumulative Claims data for TPAs 42- 44 Annual Certificate in the matter of Working Capital and income of a 45 TPA Company. Annual Declaration and Undertaking by a TPA Company 46 Annual Form on Service Level Agreement Details 47 Minimum Standard clauses in agreement between Insurer and TPAs 48-49 Minimum Standard clauses in agreement between Insurer, TPAs and 50-72 Network Providers as the case may be. Periodical returns - Half-yearly information on non-insurance health 73 schemes Stipulations in the matter of Non Insurance Services under Health 74 Care Schemes Format for Half-yearly Information on services rendered in India or in 75 foreign jurisdictions for policies issued by Indian Insurers Format for Half-yearly Information on health services rendered to 76 foreign travel policies issued by Foreign Insurers Corporate Governance norms for TPAs 77-78 Form for intimation of opening and closing of the branches or change 79-81 in office address. Maintenance of Records 82 Claim Forms and Pre-Authorization Forms 83-89 i:rft~~, mmrcm, ci!!/0(,itlll , ~-500004. 'lfmf ({) : 91-040-2338 1100, ~ : 91-040-6682 3334 i -i@: irda@irda.gov.in ~: www.irda.gov.in Page 2 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-23381100, Fax: 91 -040-6682 3334 E-mail : irda@irda.gov.in Web.: www.irda.gov.in 1. OBJECTIVE: t11;1am INSURANCE REGULATORY AND inlai DEVELOPMENT AUTHORITY OF INDIA IRDAI (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 tbis circular. -qtt?;Tq 'lfcR, <flmT <@, iil:/Al.iillll, ~-500 004. ~ (() : 91-040-2338 1100, tl;cm: 91-040-6682 3334 {-i@: irda@irda.gov.in ~: www.irda.gov.in Page 3 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-2338 1100, Fax: 91-040-6682 3334 E-mail: irda@irda.gov.in Web.: www.irda.gov.in inlai ~ 1 ufl t1 inn R4f.:It111-1 ch 3m R4 chm ~ INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA 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. "tlft9All ~. moo <R1, cil:iA<~llll, ~-500 004. ~ (() : 91-040-2338 1100, ~ : 91-040-6682 3334 t-i8: irda@irda.gov.in ~: www.irda.gov.in ~;~;.~~,a~ ~\\l Joint Director (Health) Page 4 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-23381100, Fax: 91-040-6682 3334 E-mail: irda@ irda.gov.in Web.: www.irda.gov.in Page 5 of 89 Annexure – 1 As per Regulations 7 (1) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 1 APPLICATION FOR GRANT OF CERTIFICATE OF REGISTRATION TO TPA Instructions for filling up the form: 1. It is important that before this application form is filled in, the regulations made by the Authority are studied carefully. 2. Applicant must submit a duly completed application form together with all appropriate, supporting documents to the Authority. 3. Application for registration will be considered only if it is complete in all respects. 4. A separate Fit & Proper criteria form shall be submitted in respect of Directors, Promoters, Shareholders and Key Managerial Personnel appointed by the applicant Company,. Where any of the Key Managerial Persons referred herein is appointed subsequent to receipt of Certificate of Registration, form shall be submitted subsequently as specified in TPA – 2 or TPA – 3. 5. Application for grant of Certificate of Registration (CoR) to the TPA shall be signed by at least two directors of Applicant Company. 6. Information which needs to be supplied in more details may be given on separate sheets which should be attached to the application form.