Processing Cashless Insurance Claims in Your Clinic: TPA & Insurer Guide for India

Understanding TPA Empanelment

A TPA (Third Party Administrator) is the intermediary between insurance companies and healthcare providers. TPAs process cashless claims, manage pre-authorisations, and settle bills directly with your clinic. Major TPAs operating in India:

To get empanelled, apply directly to each TPA's provider network team. Each TPA has different criteria — typically minimum bed count (for hospitals), NABH/JCI accreditation for higher tiers, and infrastructure requirements.

For outpatient/day-care clinics: many TPAs have a separate “clinic empanelment” track with lower requirements than hospital empanelment. Contact their provider relations team specifically for this track.

Cashless Claim Process

Pre-Authorisation: Getting It Right

Pre-authorisation (pre-auth) is the TPA's approval of cashless treatment before it is provided. A rejected pre-auth means the patient must pay upfront and later seek reimbursement — a poor experience that drives patients to other clinics.

What to include in a strong pre-auth request:

• ✓Patient policy number and TPA ID card number
• ✓Correct ICD-10 diagnosis code (TPAs mostly still use ICD-10)
• ✓Proposed procedure with CPT/CGHS procedure code
• ✓Estimated cost breakdown (consultation, diagnostics, medicines, procedure fee)
• ✓Supporting clinical notes or investigation reports that justify the procedure
• ✓Treating doctor name and registration number

Common Rejection Reasons & Prevention

For billing software that integrates TPA claim submission, see CliniqFlo GST & insurance billing.

FAQ

Can an outpatient clinic get TPA empanelment, or is it only for hospitals?

Both. Most major TPAs have separate empanelment tracks for OPD clinics, day-care centres, and diagnostic labs. Day-care procedures (cataract, minor surgeries, chemotherapy, dialysis) are the most commonly cashless-eligible at non-hospital facilities. Pure OPD consultation cashless is still limited to corporate health policies.

How long does TPA empanelment take?

Typically 30–45 days from application submission to approval, assuming all documents are in order. Delays usually occur from missing infrastructure certificates (fire NOC, biomedical waste certificate) — prepare these before applying.

What is the difference between cashless and reimbursement claims?

In cashless claims, the TPA pays your clinic directly. In reimbursement claims, the patient pays you and then claims from their insurer. From your clinic's perspective, cashless is preferred (immediate payment) but requires empanelment. Reimbursement claims don't require empanelment but create patient friction.