Pre-authorisation of the cashless health insurance process is a process of availing medical services without paying them in advance. This is possible only when the treatment takes place after the insurance company is contacted and agrees to it. The usual steps involved include the following:
Notification: Just before getting hospitalised or availing
of particular medical facilities, the policyholder or the medical practitioner
has to give advance notice to the insurance company.
Documentation: For this reason, the patient's medical
history, treatment, and the tests the patient may be required to undergo should
be submitted to the insurance provider for evaluation.
Evaluation and Approval: After doing this, they determine
whether the proposed treatment will be covered under the policy, as well as
check the basis for medical necessity or limits imposed by the policy.
Authorisation Issuance: Once the sum is sanctioned, the
insurance company releases a pre-authorisation number. This enables the
hospital to treat the patient without taking any amount from the latter
beforehand.
Cashless Settlement: The hospital forwards the treatment
bill to the insurance company once it discharges the patient. The insurance
company pays the amount as relevant under the terms of the policy applicable to
the case.
Benefits of Pre-Authorization in Cashless Health Insurance
The following are the benefits that the cashless health insurance provides with its pre-authorisation:
Financial Convenience: All treatments are available through
a cashless facility for which there is no need for advance payments so that
financial stress is diminished in case of an emergency.
Convenience and simplicity of the process: Cashless facility
smoothens the billing process, enabling patients to recuperate rather than
fending with bills, claims, etc.
No surprises: Pre-authorisation confirms whether the
treatment proposed has any coverage under the policy, so that the nasty
surprise during the final bill is eliminated.
Efficient Care: This is because the hospital gets the
treatment delivered without any undue delay; this ensures the quality of care
delivered to the patient.
Less Paperwork: Patients have less paperwork to manage
because the insurance company directly settles the bill with the healthcare
provider.
Access to Network Providers: Many insurers have a network of
hospitals offering cashless services; this is how patients get quality
treatment.
Verification of Medical Necessity: The procedures ensure
that all treatments provided are medically necessary, thereby ensuring
appropriate and effective medical practices.
Informed Patient Decisions: It educates patients about what
treatments are covered. This helps patients plan better and make decisions
about their health care.
Overall, pre-authorisation enables cashless health insurance
because it provides financial protection, facilitates the access of patients to
care, and ensures that the patients receive the right kind of treatment.
What is the Cashless Health Insurance Pre-authorisation Process?
There are several steps involved in procuring authorisation
for any cashless health insurance. Following the procedure of getting
authorisation by the policyholder or healthcare provider such that the medical
treatments are accessed and covered by the insurer before administration of
them is as follows:
Notification
The initial process of notification follows, wherein the
policy holder or healthcare provider needs to notify the insurance company
about his or her instant requirement for hospitalisation or other necessary
medical services, a process that can often be completed by phone, online
portal, or some other portal.
The provider submits the forms to the insurance company.
This usually, though not necessarily, includes:
- Patient history
- Diagnosis
- Treatment plan
- Any appropriate test results or imaging reports
- Certain companies have special application forms.
Insurance Company Review
The insurance company examines everything it receives to
determine the following:
- If the proposed treatment is medically necessary
- If the proposed treatment is covered under the policy
- If it has exclusions
- If there are limitations
A medical team or claims adjuster will typically complete
this review.
Decision
The insurer reaches a decision:
- Refusal: The care is deemed reasonable and within the
policy. In this case, a pre-authorisation number is issued.
- Denial: The care is not eligible or not required. In this
case, the insurer communicates with the patient and the healthcare provider,
stating that it denies the care and provides reasons.
Acceptance Communication
Upon acceptance, the insurer notifies the patient and the
healthcare provider of the pre-authorisation number and other relevant details.
This quantum is highly required for cashless treatment
during a hospital stay.
Cashless Treatment
In this course of admission, the patient submits
pre-authorisation details to the hospital.
The hospital verifies with the insurer and agrees to treat
the patient without collecting advance from the patient.
Billing and Settlement
After the patient is discharged, the hospital sends the bill
to the insurer.
The insurer checks the prescription against the
pre-authorised treatment and pays the bill directly at the hospital based on
the terms of the policy.
The pre-authorisation process all together ensures that the
patients get necessary medical care while providing financial protection and
streamlining the payment process in different types of health insurance.
Conclusion
In conclusion, the cashless pre-authorisation process under
cashless health insurance is an especially important mechanism that allows for
smooth access to required medical treatments while providing financial
protection to the insured. The process tends to check the validity of the
treatment and its medical necessity and reduces the burden of upfront payments.
All these structured measures promote effective delivery of
health care, reduce paperwork, and make communication among patients,
healthcare providers, and insurers accessible. Knowing the process of the
pre-authorisation mechanism enables everyone to provide better services for the
patients, letting them have a peaceful life while on the road to recovery.
