Preauth Doctor Consent Process Overview: Facilitating Doctor Approval for Pre-Authorizations

1. Introduction: Understanding Preauth Doctor Consent

This comprehensive guide provides a high-level overview of how our system manages the crucial step of obtaining a doctor's consent for pre-authorisation requests.

The Preauth Doctor Consent process, through the Doctor Consent workflow, is designed to ensure that all pre-authorisation requests submitted to the Social Health Authority (SHA) have the necessary medical approval from the attending doctor. It's about moving from a prepared pre-authorisation request to one that is officially verified by the responsible medical professional.

1.1. Why This Full Process Matters

The Preauth Doctor Consent process is fundamental to compliant and medically justified healthcare delivery. It is crucial because it:

• Ensures Medical Accountability: Verifies that a qualified medical professional reviews and approves the planned intervention.
• Validates Medical Necessity: Strengthens the medical justification for the pre-authorisation request, increasing the likelihood of SHA approval.
• Maintains Regulatory Compliance: Adheres to requirements that mandate doctors' consent for certain procedures and treatments.
• Prevents Claim Denials: Reduces the risk of pre-auth requests being denied due to missing or unverified medical consent.

2. The Full Preauth Doctor Consent Journey: Step-by-Step Doctor Approval

The complete Preauth Doctor Consent process is centred around the Doctor Consent workflow. This ensures medical approval is secured before a pre-authorisation can proceed.

2.1. Step 1: Doctor Consent Workflow

This foundational step involves prompting a consent request to be sent to the attending doctor on a preauth, and allowing them to approve or reject it.

This step is vital for ensuring every pre-authorisation request has explicit medical backing. Without the doctor’s consent, the preauth is incomplete and cannot be submitted to SHA.

3. Workflow Details: Doctor Consent

3.1. Workflow Description: Step-by-Step System Behavior

When a preauth request requires doctor consent, here’s what happens:

1. Consent Prompt Initiation
   A request is triggered to send a consent prompt to the attending doctor.

2. Doctor and Facility Validation

   • Verify that the doctor exists in the health worker registry.
   • Check the facility’s registration and ability to transact.
   • Confirm the doctor has a valid KMPDC license.

3. Consent Request Delivery
   The system sends an SMS (and optionally email) to the doctor with preauth details and a consent prompt.

4. Doctor Response Reception
   The doctor responds via SMS (typically with a code) indicating approval or rejection.

5. Preauth Status Update
   Based on the response, the system updates the pre-authorisation request accordingly.

3.2. Key Validations: Our System's Essential Checks

• Valid Doctor License (KMPDC)
  Only doctors with a valid license can consent.

• Doctor Existence in Registry
  The doctor must exist and be verifiable in the national health worker registry.

• Valid Facility
  The facility must be registered and authorized to transact.

• Consent Request Delivery
  The system must successfully send the SMS/email request to the doctor.

• Consent Response Handling
  The system must be able to receive and process the doctor's response (typically SMS).

3.3. Expected Outcomes from this Workflow

• Success: Doctor Consent Approved
  The request is sent and the doctor approves. The preauth now includes medical consent and may proceed.

• Success: Doctor Consent Rejected
  The request is sent and the doctor rejects it. The preauth cannot continue and must be reviewed or cancelled.

• Failure: Invalid Doctor or Facility
  The doctor or facility ID is missing, unregistered, or unauthorized. The consent request is blocked until valid details are provided.