Master circular for TPAs

MASTER CIRCULAR Master Circular as per the provIsIons of IRDAI (Third Party Administrators - Health Services) Regulations, 2016 and subsequent amendments thereof, applicable to all applicant TPAs, registered TPAs and insurers carrying out health insurance business. Circular Reference No. IRDAI/TPA/REG/CIR/130/06/2020, dated 03.06.2020 Issued on: 03.06.2020 Page 1 of 97 INDEX Sr. Annexure No. Form No. Particulars Page No No. 1 -- -- Objective 3 2 -- -- Applicability 3 3 -- -- Leqal & other provisions 3 4 -- -- Effective Date 4 5 Annexure - 1 TPA-1 Application for Grant of Fresh Certificate of Rec:iistration to TPA 5 - 10 6 Annexure - 2 -- Check-list for Documentation to be submitted along with Form TPA - 11 1 and Procedural requirements for obtaininq Fresh TPA Rec:iistration 7 Annexure - 3 TPA-1A Format for Certificate of Reqistration 12 8 Annexure - 4 TPA- 2 Declaration and Undertaking with respect to fit and proper criteria 13-16 9 Annexure - 5 TPA- 3 Form for Intimation of appointment or change in Director, or Key 17 Manaqerial Personnel. 10 Annexure - 6 TPA-4 Aoolication for issue of Duplicate Certificate of Reqistration. 18 11 Annexure - 7 TPA-4A Format for Duplicate Certificate of Registration 19 12 Annexure - 8 TPA- 5 Aoolication For Chanc:ie In Shareholdinc:i Pattern 20- 21 13 Annexure - 9 -- List of documents to be submitted for consideration of application for 22-23 chanqe in shareholdinq pattern 14 Annexure - 1 O TPA- 6A Status of Shareholding Pattern of a TPA Company 24 15 Annexure - 11 -- Minimum Business Requirements for TPAs 25 16 Annexure - 12 TPA- 7 Application for Renewal of Certificate of Reqistration 26-28 17 Annexure - 13 -- List of documents to be attached with the Application for Renewal of 29 TPA Reqistration. 18 Annexure - 14 TPA- 7A Format for Certificate of Renewal of TPA Registration 30 19 Annexure - 15 -- List of documents to be submitted along with application for Voluntary 31 Surrender of TPA Rec:iistration. 20 Annexure - 16 TPA- 8 Form for Annual Report by TPA and Schedule 1 to 7 under the said 32- 41 form TPA-8. 21 Annexure - 17 TPA- 68 Format for annual Claims data for TPAs 42- 44 22 Annexure - 18 TPA- 6C Annual certificate in the matter of Net Worth of a TPA Company 45 23 Annexure - 19 TPA- 60 Annual Declaration and Undertaking by a TPA Company 46 24 Annexure - 20 TPA- 6E Annual Form on Service Level Agreement Details 47 25 Annexure - 21 -- Minimum Standard clauses in aqreement between Insurer and TPAs 48-49 Annexure - 22 -- Minimum Standard clauses in agreement between Insurer, TPAs and 50-72 Network Providers as the case may be. 26 Annexure - 23 TPA- 6F Periodical returns - Half-yearly information on non-insurance health 73 schemes 27 Annexure - 24 -- Stipulations in the matter of Non Insurance Services under Health 74 Care Schemes 28 Annexure - 25 TPA- 6G Format for Half-yearly information on services rendered in foreign 75 jurisdictions for policies issued by Indian insurers. 29 Annexure - 26 TPA- 6H Format for Half-yearly information on health services rendered to 76 policies issued by foreic:in insurers. 30 Annexure - 27 -- Corporate Governance norms for TPAs 77-78 31 Annexure - 28 TPA - 9 Form for intimation of opening and closing of the branches or change 79-81 in office address. 32 Annexure - 29 -- Maintenance of Records 82 33 Annexure -30 -- Claim Forms and Pre-Authorization Forms 83 Page 2 of 97 1. OBJECTIVE: IRDAI (TPA- Health Services) Regulations, 2016 were notified on 14th March 2016 and subsequently amendment Regulations were notified on 4th December 2019. Vide various provisions of the said regulations the Authority is empowered to specify the Regulatory Norms, Forms, Formats, and Check list etc., for compliance by all TPAs and other regulated entities, as may be applicable. The objective of this master circular is to consolidate all the regulatory requirements stipulated under various circulars referred hereunder and to enable the concerned applicant or registered entity, as the case may be, 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 Master Circular is issued under the provisions of Section 14 (1) of IRDA Act, 1999 and under the powers vested under the provisions of various regulations of IRDAI (TPA- Health Services) Regulations, 2016 as amended from time to time. 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. Page 3 of 97 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. 4.4 Cashless Authorization Letter Part - D 5. This master circular supersedes the following circulars: 5.1 Circular Reference no: IRDA/TPA/REG/CIR/059/03/2016 dated 28-03-2016: (First Circular). 5.2 Circular Reference no: IRDAI/HLT/REG/CIR/015/02/2018 dated 02-02-2018: (Second Circular). 5.3 Circular Reference no: IRDA/HL T/REG/CIR/86/05/2019 dated 27-05-2019: (Third Circular). 6. Effective date: The provisions of this circular shall be applicable with immediate effect or as specified in the respective provisions of this circular. ~ D VS Ramesh, General Manager (Health) Page 4 of 97 Page 5 of 97 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 Personnelappointed 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. 1 PARTICULARS OF THE APPLICANT: 1.1 Name of the Applicant / TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 (B) Address for Correspondence: Principal Place of business or Corporate Office Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.4 (c) Name of Chief Executive Officer or Chief Administrative Officer.