Page 93 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

c) Decision support system

This is where the computerized system will process and generate management

analysis reports on the cost and utilization pattern for review or decisions to be taken.

Coding

At first, claims were processed against textual description of the medical diagnosis

and surgical procedures. Generally, they were classified in broad categories of

diagnosis related group coding by most insurance company' own classifications.

However, in Malaysia, it was recommended by the insurance association to follow the

common standard coding mechanism determined by the hospital network and the

Ministry of Health.

The coding allowed for more correct assessment and helped in the analyzing of costs
and so on.

In the industry standardized claim form, the provider is required to indicate the

relevant diagnosis ICD 10 codes.

5.2 PRE-AUTHORISATION

Pre-authorization or pre-certification is a utilization review tool used by Managed-

care Organizations, Third-Party Administrators or insurance company to manage

claims costs. In order to pre-authorize a service, the Managed-care Organizations,

Third-Party Administrators and insurance company requires the provider to submit a
pre-authorization request form indicating the types of medical treatment required

with the presenting symptoms and diagnosis and estimated costs. Pre-authorization is

often used to approve a hospital admission whereby a guaranteed letter will be
provided if the medical condition is admissible to a panel hospital.

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