Officer TPA ,Recoveries , Claim Settlement

Job Description- Officer – TPA & Recoveries
o To do documentation for Mediclaim for TPA, PSU and Govt Healthcare bodies of
both OPD & IPD patients.
o Daily coordination with other departments like accounts, OT/doctors, Counselling
Department, Front end TPA recovery Team.
o Getting Claim Approval letters from TPAs.
o Validating the required documents before processing the cases such as insurance
papers, TPA card, Govt. id proof, Pan card along with patient details & documents
provided by patients.
o Sending of physical paper base Patient Dockets to TPA with one copy in SCEH file.
o Keeping acknowledgement of the received dockets at TPA end.
o Data-entry of all Insurance, Patient and Operation and Claim related information in
to database.
o Handling email & revert / making good on them (like shortages in patient dockets.
Payment related, processing, quires etc.)
o TPA case and payment processing for all the centers.
o Making follow-up calls to TPAs on Claim Approvals, Payment release, Deviations,
Deficiencies. Short Payments.
o Informing patients regarding approvals
o Scanning claim bundles /bill/ dockets which is to be send to the TPA for releasing
payments.
o Checking every claims bills including bills documents such as covering letter,
treatment bill, discharge summary, IOL invoice etc before submission of the Final
Claim.
o Updating of Case-wise status with the TPA Field Recovery Team.
o Validation of received payments with Finance and accounts department on a daily
basis on previous days received payments.
o Dispute handing in exceptional cases on TPA / Patient and Filed Recovery Team.
o Updating processing sheet on daily basis.
o Updating payments on daily basis.
o Ensuring daily back-ups of the Master file on Server.
o Being a 100 percent back-up of co-worker and being each-others back-up in case of
absence of one.
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o Maintaining master sheets, taking follow ups for payment related quires/
deductions.
o Dispatching final claim bills/ bundles to the concern TPA and keeping case-wise
Proof of Delivery with the case to the TPA.
o Updating dispatch register of each and every cases on daily basis.
o Being the custodian of all TPA Agreements / MOUs (soft and hard copy) and
maintaining a tracker for renewals.
o Rate agreements with TPA (Mails and Hard copies) to be kept on file in an auditable
manner.
o Month and Year-wise physical files to be maintained for cases for easy retrieval and
access.
o Co-ordinating with other Secondary Centers for the same job for their centers.
o Travel to other centers, if required.
o To Solve cashless/ claims quires such as patient’s payment details, KYC Documents,
revision of Rates etc. on daily basis through mails and calls.
o Any other responsibility that the supervisor may require to be done from time to
time.
o Escalate matters to seniors that are beyond your area of understanding / routine /
sphere of influence / power.
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