Description

Course Name: Certificate in Health Insurance Claims and TPA Services

Global Occupational Skill Standard – GOSS ID: GOSS/HF/CHICTPAS/V1

Eligibility: 10+2 (Higher Secondary) or Equivalent.

Duration: Three Months.

Objective: The Certificate in Health Insurance Claims and TPA Services course is designed to equip professionals with comprehensive knowledge and practical skills required to manage and operate third-party administration (TPA) services effectively. The course focuses on the end-to-end understanding of TPA operations, including claims management, regulatory compliance, risk assessment, customer service excellence, and operational efficiency.

Get ready to join the Journey to become a GSDCI Certified Professional  – International Certification and Assessment Body.

Steps to become a GSDCI Certified Professional:

Step 1: Select your certification you want to pursue.

Step 2: Click on get certified tab, new pop up window will open.

Step 3: Click on pay certification fee, you will be redirected to billing details page.

Step 4: Fill your details and click on pay certification fee, you will be redirected to payment gateway, pay fee by any available options like Card (Debit/Credit), Wallet, Paytm, Net banking, UPI and Google pay.

Step 5: You will get Login Credentials of Online E-Books and Online assessment link on your email id, within 48 hrs of payment.

Step 6: After completion of the online assessment, the soft copy of your certificate will be sent to your registered email ID within 5 days.

Assessment Modules:

Module 1: Introduction to TPA Operations: Overview of TPAs and their role in healthcare, Roles and responsibilities of a TPA operations executive, Structure of health insurance and managed care, Regulatory and legal framework governing TPAs, Key concepts in claims management, Ethical and professional standards in TPA operations

Module 2: Health Insurance Products and Policies: Understanding health insurance products, Policy types and coverage, Terms and conditions of insurance policies, Pre-authorization and approvals, Exclusions and limitations, Policy renewals and endorsements

Module 3: Claims Management Process: Claims submission and documentation requirements, Claims verification and adjudication, Pre-authorization and claim approval workflows, Denial management and appeals process, Coordination with hospitals and healthcare providers, Claims reporting and record-keeping

Module 4: Customer Service and Client Relations: Handling client inquiries and grievances, Communication skills for TPA operations, Managing corporate and individual client accounts, Maintaining service level agreements (SLAs), Patient education on insurance processes, Building trust and long-term client relationships

Module 5: Financial and Administrative Management: Billing and reimbursement processes, Coordination with insurers and providers, Cost control and audit processes, Resource allocation and workflow optimization, Documentation and compliance reporting, Performance monitoring and KPIs

Module 6: Technology, Data Management, and Compliance: Use of TPA management software and health IT systems, Electronic claims processing and tracking, Data collection, analysis, and reporting, Regulatory compliance and audits, Risk management and fraud prevention, Continuous improvement in TPA operations

GSDCI Online Assessment Detail:

• Duration- 60 minutes.
• Number of Questions- 30.
• Number of Questions from each module: 5.
• Language: English.
• Exam Type: Multiple Choice Questions.
• Maximum Marks- 100, Passing Marks- 50%.
• There is no negative marking in any module.

Benefits of Certification:

1. Global Recognition & Credibility – Stand out worldwide with a certification that strengthens your professional profile across borders and demonstrates your skills to employers and institutions.

2. Quality Assurance through ISO Certification – Programs follow an ISO-certified quality management system to promote consistency, reliability, and a standardized learning experience.

3. Career Advancement & Employability – Enhance your résumé, demonstrate professional competence, and improve your prospects for career growth, promotions, or suitable job opportunities.

4. Non-Profit Trust Factor – Certification from a non-profit organization reflects a mission-driven approach focused on skill development, professional learning, and public benefit.

5. Access to Learning Resources – Gain access to useful learning resources such as e-books, mock tests, assessments, and online academic support.

6. Transparency & Online Verification – Each certification includes a unique enrolment or certificate ID, enabling convenient online verification by employers and other interested parties.

7. Lifetime or Long-Term Validity – Certifications may offer lifetime or extended validity, reducing the need for frequent renewal, subject to the applicable certification scheme.