Insurance Claims (TPA)

Cashless treatment through a third-party administrator. A claim is drafted against an admission with the policy and pre-authorisation details, the TPA approves an amount (and may enhance it), the discharge bill is raised, and settlement records what the TPA paid, what was disallowed, and what the patient owes as co-pay or deductible.

Switch: Settings > Hospital > Insurance Claims (TPA) (needs IPD on). Permission: Manage Admissions.

Where it appears

Hospital shell: Inpatients (IPD) > Insurance Claims (TPA). TPAs are contacts (a supplier-style ledger) so their receivable shows on statements. Report: Claim Register.

Flow

flowchart TD
    A[Admission] --> C[New claim: TPA · policy · member id · corporate
sum insured · diagnosis code · initial requested amount]
    C --> PA[Pre-auth request · reference number]
    PA --> CL[(Claim requested)]
    CL --> AP{TPA response}
    AP -->|approved| APR[approvedAmount · approvedOn]
    AP -->|query| Q[queryNotes · resend]
    AP -->|denied| DN[denialReason · patient pays]
    APR -->|more needed| EN[Enhancement request → enhancedAmount]
    APR --> D[Discharge bill raised]
    D --> ST[Settlement: settledAmount · disallowed · co-pay % · deductible]
    ST --> R[(Receivable on TPA · patient pays balance)]
    R --> P[Payment In from TPA when it arrives]

The claim tracks the negotiation; the money still flows through ordinary receivables and Payment In.

Screens

Insurance Claims - claims by status (requested, approved, queried, denied, settled) with TPA, patient, amounts.
Claim form - drafts or edits the pre-authorisation.
Settlement dialog - settled, disallowed, co-pay and deductible; splits the discharge bill between TPA and patient.

Setting it up

flowchart LR
    A[Inpatients already on] --> B[Settings > Hospital
Insurance Claims on]
    B --> C[Add your TPAs as contacts]
    C --> D[Draft a claim against an admission
policy · member id · requested amount]
    D --> E[TPA approves an amount]
    E --> F[Discharge bill split: TPA share and patient share]
    F --> G[Settlement recorded when the TPA pays]

Switch it on, put the master behind it in place, then do the first one — in that order, or the first one will not have anything to pick.

Reports

Claim Register, Patient Dues, Receivable Parties (TPAs).