Insurance Regulatory and Development Authority of India

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

INDEX

Sr. No Annexure No. Form No. Particulars Pag No.e
1 Objective 3
2 Applicability 3
3 Legal & other provisions 3
4 Effective Date 4
5 Annexure – 1 TPA – 1 Application for Grant of Fresh Certificate of Registration to TPA 5 — 10
6 Annexure – 2 Check-list for Documentation to be submitted along with Form TPA – 1 and Procedural requirements for obtaining Fresh TPA Registration 11
7 Annexure — 3 TPA – 1A Format for Certificate of Registration 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 Managerial Personnel. 17
10 Annexure — 6 TPA – 4 Application for issue of Duplicate Certificate of Registration. 18
11 Annexure — 7 TPA – 4A Format for Duplicate Certificate of Registration 19
12 Annexure — 8 TPA – 5 Application For Change In Shareholding Pattern 20- 21
13 Annexure — 9 List of documents to be submitted for consideration of application for change in shareholding pattern 22-23
14 Annexure — 10 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 Registration 26-28
17 Annexure — 13 List of documents to be attached with the Application for Renewal of TPA Registration. 29
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 Surrender of TPA Registration. 31
20 Annexure — 16 TPA — 8 Form for Annual Report by TPA and Schedule 1 to 7 under the said form TPA-8. 32- 41
21 Annexure — 17 TPA — 6B 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 — 6D 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 agreement between Insurer and TPAs 48-49
Annexure — 22 Minimum Standard clauses in agreement between Insurer, TPAs and Network Providers as the case may be. 50-72
26 Annexure — 23 TPA — 6F Periodical returns – Half-yearly information on non-insurance health schemes 73
27 Annexure — 24 Stipulations in the matter of Non Insurance Services under Health Care Schemes 74
28 Annexure — 25 TPA — 6G Format for Half-yearly information on services rendered in foreign jurisdictions for policies issued by Indian insurers. 75
29 Annexure — 26 TPA — 6H Format for Half-yearly information on health services rendered to policies issued by foreign insurers. 76
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 in office address. 79-81
32 Annexure — 29 Maintenance of Records 82
33 Annexure —30 Claim Forms and Pre-Authorization Forms 83

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.

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/HLT/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 V S Ramesh,
General Manager (Health)

Download Full Circular

More Under Corporate Law

Leave a Comment

Your email address will not be published. Required fields are marked *

Search Posts by Date

October 2020
M T W T F S S
 1234
567891011
12131415161718
19202122232425
262728293031