Insurance Regulatory and Development Authority of India
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
|Sr. No||Annexure No.||Form No.||Particulars||Pag No.e|
|3||—||—||Legal & other provisions||3|
|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|
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.
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)