GR-4 GR-4 General Requirements for TPAs
GR-4.1 GR-4.1 Compensation
GR-4.1.1
A TPA's compensation may be determined:
(a) As a percentage of the claims processed by the TPA; or(b) On another basis as specified in the written agreement.April 2016GR-4.2 GR-4.2 Code of Conduct
GR-4.2.1
TPAs are allowed to enter into agreement with more than one:
(a) Insurance firm; and/or(b) A self-funded scheme outside of Bahrain.April 2016GR-4.2.2
TPAs must not charge any kind of fees to the claimants/policyholders.
April 2016GR-4.2.3
TPAs must not market or sell insurance nor own any part of a healthcare facility or company.
April 2016GR-4.2.4
Where a TPA owns any part of a healthcare facility or company at the time this Module is issued, it will be permitted to retain its ownership in the company.
April 2016GR-4.2.5
TPAs must act in the insurance firm's and/or self-funded scheme's (limited to outside Bahrain) best interests at all times and must fulfill their needs to the best of their ability.
April 2016GR-4.2.6
TPAs must improve the skills of their employees and increase their knowledge through continuing education and training.
April 2016GR-4.2.7
TPAs must disclose to the existing and prospective insurance firm and/or self-funded scheme (limited to outside Bahrain) any and all information that may affect the TPA's ability to provide services and/or advice to the clients.
April 2016GR-4.2.8
TPAs must ensure that all client funds collected and/or held by the TPA are used for the express purpose for which the funds are collected and/or held as understood by the insurance firm and/or self-funded scheme (limited to outside Bahrain).
April 2016GR-4.2.9
TPAs must fully disclose to each insurance firm and/or self-funded scheme (limited to outside Bahrain) the terms of engagement and the services to be rendered to that client.
April 2016GR-4.3 GR-4.3 Segregation of Funds
GR-4.3.1
All funds remitted to a TPA by an insurance firm and/or self-funded scheme (limited to outside Bahrain) must be held by the TPA in a separate account maintained in the name of the insurance firm and/or self-funded scheme (limited to outside Bahrain) or in a separate account maintained jointly in the names of the insurance firm and/or self-funded scheme (limited to outside Bahrain) and the TPA.
April 2016GR-4.3.2
When funds are collected by a TPA from a healthcare provider on behalf of an insurance firm and/or self-funded scheme (limited to outside Bahrain), such funds must be promptly deposited in a separate account maintained in the name of the insurance firm and/or self-funded scheme (limited to outside Bahrain) or an account maintained jointly in the names of the insurance firm and/or self-funded scheme (limited to outside Bahrain) and the TPA, or remitted to the insurance firm and/or self-funded scheme (limited to outside Bahrain), as provided for in the agreement.
April 2016GR-4.3.3
When an account is held jointly in the names of the insurance firm and/or self-funded scheme (limited to outside Bahrain) and the TPA, the TPA must provide the insurance firm and/or self-funded scheme (limited to outside Bahrain) on a monthly basis a record of all transactions in the joint account.
April 2016GR-4.3.4
Funds must not be commingled with any other funds of the TPA nor other insurance firm and/or self-funded scheme (limited to outside Bahrain) of the TPA. Records of a TPA must clearly show funds received and paid out allocated per insurance firm and/or self-funded scheme (limited to outside Bahrain) and must be made available to the insurance firm and/or self-funded scheme (limited to outside Bahrain) upon request.
April 2016GR-4.3.5
An insurance firm and/or self-funded scheme (limited to outside Bahrain) shall have the responsibility to make available to the TPA funds necessary to enable the TPA to pay claims in a timely manner, as provided in the agreement.
April 2016GR-4.3.6
TPAs must process and settle claims of the policyholder/claimant within 15 calendar days from the receipt of all necessary documents.
April 2016GR-4.3.7
TPAs must process and settle claims from healthcare service providers within 30 calendar days from the receipt of all necessary documents from the healthcare service providers.
April 2016GR-4.4 GR-4.4 Content of Written Agreement
GR-4.4.1
A TPA must not conduct any business with an insurance firm and/or self-funded scheme (limited to outside Bahrain) in the absence of a written agreement between the TPA and the insurance firm and/or self-funded scheme (limited to outside Bahrain). The agreement must be retained as part of the official records of the TPA for the duration of the agreement.
April 2016GR-4.4.2
The agreement referred to in Paragraph GR-4.4.1 must include at a minimum:
(a) The services to be provided by the TPA on behalf of the insurance firm and/or self-funded scheme (limited to outside Bahrain);(b) Financial arrangements;(c) Provisions setting forth the respective liability of the insurance firm and/or self-funded scheme (limited to outside Bahrain) and the TPA for the accuracy and eligibility of submitted claims, and for the prompt submission of claims; and(d) The responsibilities of the TPA to the insurance firm and/or self-funded scheme (limited to outside Bahrain) with respect to the maintenance of appropriate back-up systems against the loss of records, and the maintenance of appropriate insurance coverage by the TPA against the risk of loss.April 2016GR-4.5 GR-4.5 Prohibition of Collection of Premiums/Contributions
GR-4.5.1
TPAs are prohibited from collecting premiums/contributions from policyholders. Premiums/contributions must be paid directly by the policyholders to insurance firms.
April 2016
