Preauthorizations

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Preauths Process Guide: Imaging Preauth Workflow

1. Overview: Authorising Specialised Diagnostic Imaging Services

This guide details the Imaging Preauth Workflow, a specialised preauth form which is part of the broader Preauths Process. This workflow is specifically designed to facilitate the submission of pre-authorisation requests for Imaging interventions (such as MRI, CT scans, advanced X-rays, and ultrasounds) that require prior approval from the Social Health Authority (SHA) for payment.

Imaging preauth is a type of elective preauth and therefore this workflow ensures that patients needing specialised diagnostic imaging receive necessary prior approval, providing financial assurance and enabling the appropriate and compliant utilisation of these often high-cost services.

2. Workflow Details: Submitting an Imaging Preauth

This section details the step-by-step process for submitting an imaging pre-authorisation request.

2.1. Step-by-Step System Behavior

1. Input Reception: The system receives the consent_token for the patient's active visit, the intervention_code for the imaging procedure, clinical_indications, and arrays of items, diagnoses, doctors, and attachments.

2. Authorisation and Visit Context Check: The system uses the provided consent_token to validate that the patient has a valid, active visit and that consent is still active. This also includes confirming the patient is in an active state.

3. Imaging Preauth Request Validation: The system performs comprehensive and specific checks on the incoming data and the context of the request, as per SHA's rules for imaging procedures and general elective preauthorization rules. Therefore, elective preauth validations are considered. However, Imaging Specific Mandatory Field checks are done for the presence and validity of the clinical_indications field.

4. Submit Imaging Preauth Request to SHA: If all validations pass, the system compiles the complete imaging pre-authorisation request payload and submits it to SHA's preauth service.

5. Receive SHA Response: The system receives and processes the response from SHA, which indicates the submission status (e.g., success, failure, pending review).

2.2. Key Validations

These are the critical checks performed during this workflow to ensure the accurate and compliant submission of a surgical pre-authorisation request. Imaging preauths align with the validation rules for elective procedures, hence the validations remain the same.

2.3. Workflow Data Dictionary

This table outlines the key information used and produced by this workflow for an Imaging preauth.

Field Name	Info	Options (if applicable)	Is required?	Type
consent_token	The consent token for the patient visit.		True	string
intervention_code	This should be the unique identifier for the intervention we want to do a preauth request for. You should only select the intervention that needs_a_preauth. You can know this from the previous interventions coverage response.		True	string
clinical_indications	The clinical indications.		True	string
doctors	The Attending Doctors/Clinical Officers' consent. This is an array of the doctors you need approval from.		True	array
items	This will be an array of items in the preauth request.		True	array
diagnoses	This will be an array of diagnoses in the preauth request.		True	array
attachments	This will be an array of attachments in the request.		False	array

Some items in the general workflow dictionary have their own specific workflow dictionaries. Below is the list that applies to this particular preauthorization.

2.3.1. Preauth Doctor

This component represents the details of a doctor or clinical officer whose consent is required for a pre-authorisation.

Field Name	Info	Options (if applicable)	Is required?	Type
identification_number	The unique ID for the doctor.		True	file (likely string/number for ID)
identification_type	The type of ID being used.	registration_number, National ID, Alien ID, Refugee ID	True	string
regulation_body	The licensing body's choices. Defaults to KMPDC.	KMPDC, COC, NCK	True	string
intervention_code	The intervention code is associated with the doctor's consent.		True	string
name	The client registry ID from the previous eligibility call (This might be a generic description; in context of items, likely item name).		True	string

2.3.2. Preauth Items

This component represents the individual billable items or sub-services included within a pre-authorisation request.

Field Name	Info	Options (if applicable)	Is required?	Type
unit_price	The unit price charged for this item.		True	float (up-to 2dp)
quantity	The quantity of the item.		True	float (up-to 2dp)
charge_date	The charge date for the item. Defaults to today.		False	An ISO 8601 timestamp of the date for the
scheme_name	The name of the scheme you intend to bill to.	Universal Health Coverage, Public Medical Service Fund	True	string
scheme_code	The scheme code you intend to bill against.	UHC, PMF	True	string
consent_token	The consent token for the patient visit.		True	string

2.3.3. Preauth Diagnosis

This component represents the diagnostic information associated with a pre-authorization request.

Field Name	Info	Options (if applicable)	Is required?	Type
icd_code	The ICD-11 code.		True	string

2.3.4. Preauth Attachments

This component represents the supporting documents or files that are attached to a pre-authorisation request.

Field Name	Info	Options (if applicable)	Is required?	Type
file_blob	The file blob.		True	file
document_title	Title to the document.		False	string
document_type		PRESCRIPTION, MEDICAL_REPORT, RADIOLOGY_REQUEST, LAB_ORDER, INTERIM_BILL, DISCHARGE_SUMMARY, FINAL_BILL, PROFORMA_INVOICE, THEATRE_LIST, CLINICAL_DOCUMENTATION, OTHER	True	string