Preauths Process Guide: Multisession Preauths Workflow
1. Overview: Authorising Treatments Over Multiple Sessions
This guide details the Multisession Preauths Workflow, a part of the broader Preauths Process. This workflow is specifically designed to facilitate the submission of pre-authorisation requests for healthcare interventions that require multiple sessions over an extended period. This often applies to treatments like chemotherapy, radiotherapy, or long-term physical therapy.
This workflow is meant to streamline the authorisation for continuous care, allowing for SHA approval of an entire treatment plan rather than requiring separate authorisations for each session.
1.1. What This Workflow Does
The Multisession Preauths Workflow's primary function is to submit a valid pre-authorisation request for interventions planned across multiple sessions to the Social Health Authority (SHA). It does this by:
Receiving Authorisation and Service Details: It takes a consent_token (for the patient's active visit) and the intervention_code for the multisession service.
Defining Session Parameters: It captures crucial details such as the number_of_sessions and the session_duration (e.g., number of days per session).
Gathering Comprehensive Clinical Data: It collects detailed medical information, including diagnoses, associated items (billable components), and mandatory attachments (e.g., treatment protocols, medical reports) to provide a strong medical justification for the extended treatment.
Obtaining Doctor's Consent: It ensures that necessary consent from attending doctors or clinical officers is included, as required for these ongoing treatments.
Validating Request Compliance: It performs a series of stringent checks to ensure the request meets SHA's specific criteria for multisession procedures, including restrictions on intervention types, diagnoses, facilities, and patient schemes.
Submitting the Preauth: Upon successful validation, the system submits the comprehensive multisession pre-authorisation request to SHA for review.
1.2. Why This Workflow Is Critical (The "Why It Matters")
This workflow is important because it simplifies and secures authorisation for continuous, long-term treatments, which is crucial for patient care and financial management. Similarly it helps in the following ways:
Streamlined Authorisation: It eliminates the need for repeated pre-authorisation requests for each session, significantly reducing the administrative burden for both healthcare providers and SHA.
Ensuring Continuity of Care: By authorising an entire course of treatment upfront, it ensures that patients can receive their full prescribed therapy without interruptions due to pending approvals.
Guaranteed Financial Coverage: It provides patients and facilities with financial assurance for the complete multisession treatment plan, which often involves high costs over time.
Promoting Treatment Adherence: Patients are more likely to complete their full course of treatment when financial coverage for all sessions is confirmed from the outset.
Maintaining Compliance: It ensures strict adherence to SHA's specific regulations for multisession procedures, which is crucial for operational integrity and auditability.
This workflow ensures that patients undergoing extended treatments receive continuous, authorised, and financially covered care, benefiting both patients and providers.
2. Workflow Details: Submitting a Multisession Preauth
Key Validations
These are the critical checks performed during this workflow to ensure the accurate and compliant submission of a multisession 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.
Uses child consent to start visit: For multi-session preauths, the request must be linked to a child's consent to start the visit. This ensures all preauth activities are rooted in a legitimate and authorised patient encounter.
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
2.2. Expected Outcomes
Success: Multisession Preauth Request Submitted:
All inputs were valid, the visit was active, and the multisession preauth request successfully passed all internal validations and was submitted to SHA. A preauth_id is returned. The multisession pre-authorisation request is now with SHA for review. The facility will wait 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 multisession 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, number_of_sessions, session_duration, start_date, end_date) were missing or invalid. The multisession preauth request cannot be submitted. The user needs to provide all required and valid information.
Failure: Multisession Preauth Condition Violation: The request violated one or more specific rules for multisession preauths (e.g., intervention not designated for multisession, facility not authorised, patient scheme/age mismatch, or invalid session parameters). The multisession 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.