Page 94 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

5.2.1 MEANING OF PRE-AUTHORISATION

Pre-authorization is a process of obtaining approval from the insurance company to

confirm that the patient's treatment or admission is medically necessary and is

covered by the policy.

5.2.2 PROCESS AND IMPACT OF PRE-AUTHORISATION CLAIMS

The general steps in a typical process of pre-authorization for inpatient

hospitalization, followed by 'an appointed Third-Party Administrator are as follows:

a) The claimant will have to call the Helpline of the Third-Party Administrators
giving the required information for the admission.

b) The TPA will verify if the claimant is eligible for the benefits and whether the

policy is still enforced.
c) If eligible, the Third-Party Administrators will request for the pre-authorization

form to be filled by the attending physician for the admission. The Third-Party

Administrators will assess and determine if the admission is medically

necessary within the proviso of the policy cover. If the medical condition is

covered and with approval obtained from the insurance company, an initial
Guarantee Letter will be issued to the hospital for the admission. There is a cap

on the amount of the guaranteed letter.

d) The Third-Party Administrators will monitor the progress of the patient as the
hospital may call up for a top-up GL, depending on the severity of the

treatment.

e) Upon discharge, the hospital will provide the final bill and final diagnosis and

the Third-Party Administrators will scrutinize the bill to check if there are any

discrepancies or ineligible expenses incurred.

93 | P a g e