Preauths Process Guide: Elective Preauthorization Workflow
1. Overview: Obtaining Prior Approval for Planned Procedures
This guide details the Elective Preauthorization Workflow, a part of the broader Preauths Process. This workflow is specifically designed to manage the submission of pre-authorisation requests for elective procedures – those healthcare interventions that are planned in advance.
This workflow ensures that planned procedures receive the necessary prior approval from the Social Health Authority (SHA), allowing patients and healthcare facilities to schedule and prepare for these services with confirmed financial coverage.
1.1. What This Workflow Does
The Elective Preauthorization Workflow's primary function is to submit a valid pre-authorisation request for a planned procedure to SHA. It accomplishes this by:
Receiving Authorisation and Service Details: It takes a consent_token (for the patient's active visit) and the intervention_code for the specific elective service requiring pre-authorisation.
Gathering Comprehensive Clinical Data: It collects detailed medical information such as specific diagnoses, associated items (billable components), and mandatory attachments (e.g., medical reports, lab results) to provide strong medical justification.
Obtaining Doctor's Consent: It ensures that necessary consent from attending doctors or clinical officers is included, as required for these planned procedures.
Validating Request Compliance: It performs a series of stringent checks to ensure the request meets SHA's specific criteria for elective procedures, including restrictions on intervention types, diagnoses, facilities, patient schemes, age ranges, and ensuring it's not for emergency or urgent cases.
Submitting the Preauth: Upon successful validation, the system submits the comprehensive elective pre-authorisation request to SHA for review.
1.2. Why This Workflow Is Critical (The "Why It Matters")
This workflow is vital because it ensures planned healthcare services receive necessary prior approval, which is crucial for financial certainty and compliance. This helps in:
Guaranteed Financial Coverage: It provides patients and facilities with the assurance that planned, often high-cost, elective procedures will be covered by SHA, preventing unexpected financial burdens.
Optimised Planning and Scheduling: With pre-authorisation confirmed upfront, facilities can efficiently schedule resources and patients can prepare for their procedures without uncertainty regarding payment.
Ensuring Medical Appropriateness: The requirement for detailed clinical information and the doctor's consent ensures that elective procedures are medically justified and align with SHA's guidelines for appropriate care.
Preventing Claim Denials: By fulfilling the pre-authorisation requirement for elective services, it significantly reduces the risk of claims being rejected by SHA, safeguarding the facility's revenue.
Maintaining Regulatory Compliance: It enforces strict adherence to SHA's specific regulations for elective procedures, which is crucial for the facility's operational integrity and auditability.
This workflow ensures that all planned, non-urgent healthcare services are both medically appropriate and financially covered, enabling smooth and compliant care delivery.
2. Workflow Details: Submitting an Elective Preauth
These are the critical checks performed during this workflow to ensure the accurate and compliant submission of a normal pre-authorisation request:
Active Consent/Visit State: The consent_token must be valid and correspond to an active patient visit. This ensures the preauth request is tied to an ongoing, authorised patient encounter.
At Least One Diagnosis: The request must include at least one diagnosis. This provides the medical justification for the requested interventions, an important requirement during review.
At Least One Bill Item: The request must include at least one item (bill item). This defines the specific services being requested for authorisation, necessary for financial assessment.
At Least One Attachment (if required): If the preauth type or intervention requires supporting documents, at least one attachment must be provided. This provides essential clinical evidence or justification for review.
Valid Doctor's License: At least one doctor listed in the request must have a valid license. This ensures that the requesting medical professional is duly qualified and authorised.
Financial Limits Compliance (UHC/PMF): For UHC patients, the overall bill amount must be below the defined KEPH level or overall tariff. For PMF patients, the overall bill amount must be within their PMF balance plus any ex-gratia allowance. These checks ensure the requested preauth aligns with the financial limits and policies of the patient's specific health scheme, preventing automatic rejections.
Doctor's Consent Obtained: If the intervention requires a doctor's consent (or multiple doctors' consent), this must be provided within the request. This verifies medical approval and accountability for the requested service.
Intervention Requires Preauth: The intervention_code for which pre-authorisation is sought must require pre-authorisation according to SHA's rules. This prevents unnecessary preauth submissions for services that don't require them, streamlining the process.
Has to have expected service start dates: Every elective preauthorization request must include a specific, planned expected start date for the medical service or procedure. This information is vital for scheduling, planning resources, and tracking the validity period of the preauthorization
Uses parent consent to start visit: The preauthorization request must be linked to a parent consent for a child to initiate it with proper consent. This ensures all preauth activities are rooted in a legitimate and authorised patient encounter.
2.2. Expected Outcomes
Success: Elective Preauth Request Submitted:
All inputs were valid, the visit was active, and the elective preauth request successfully passed all internal validations and was submitted to SHA. A preauth_id is returned. Here, the elective pre-authorisation request is now with SHA for review. The facility will await SHA's decision (approval, rejection, or request for more information). The preauth_id can be used to track its status.
Failure: Invalid Consent/Visit State:
The consent_token was invalid, expired, or the visit it references is no longer active. The elective preauth request cannot be submitted. The user must ensure they are using a valid token for an active visit.
Failure: Missing/Invalid Required Data:
One or more mandatory fields (diagnoses, items, doctors, attachments) were missing or invalid. The elective preauth request cannot be submitted. The user needs to provide all required and valid information.
Failure: Elective Preauth Condition Violation: The request violated one or more specific rules for elective preauths (e.g., intervention not designated for elective, facility not authorised, patient scheme/age mismatch, or attempting to submit for an emergency/urgent procedure). The elective preauth request cannot be submitted as it does not meet SHA's criteria for this type of pre-authorisation. The user needs to review the specific rule violation.