1
Roles and responsibilities
i. Carry out continuous sensitization of enrollees
ii. Market health plans to employers/enrollees
iii. Registration of eligible employers and employees
iv. Rendering to ASHIA returns on its activities as may be required;
v. Contracting only with the health care providers approved under the ASCHMA for the purpose of rendering health care services as provided by the Law
vi. Provider management and monitoring including case management, referral management, utilization management, claims management etc.
vii. Claims processing viii. Driving continuous quality improvement in their operations and those of the Health Care Providers they oversee.2
List of Requirements
a. To participate in the ASCHMA, TPAs must
i. Register with the CAC
ii. Complete the prescribed ASCHMA application forms, providing the following information:
1. Composition of the board, including their names and addresses
2. Names and addresses of the principal management officers of the TPA (where applicable)
iii. Possess necessary staff and infrastructure including computerization
iv. Maintain current accounts with accredited banks
v. Where applicable, show evidence of Audited Accounts/Statement of Affairs
vi. Provision of process manual that encompasses designated TPA functions such as:
1. Sales and marketing
2. Enrollment
3. Client management
4. Enrollee management
5. Provider management, including case management
6. Underwriting
7.Regulator relations
8. Other support of operational functions such as call center operations etc.