Preauthorizations

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Preauths Process Guide: Oncology Preauth Workflow

1. Overview: Authorising Cancer Diagnosis and Treatment Plans

This guide details the Oncology 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 oncology interventions (i.e., services related to cancer diagnosis and treatment) that require prior approval from the Social Health Authority (SHA) for payment.

An oncology preauth is a type of multisession preauth, as due to the nature of cancer treatment, it often involves multiple sessions, aligning with aspects of multisession preauths. This workflow ensures that patients undergoing cancer treatments receive necessary prior approval, providing crucial financial assurance and enabling continuous, compliant care.

2. Workflow Details: Submitting an Oncology Preauth

This section details the step-by-step process for submitting an oncology 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 oncology procedure, is_co_insured, carcinoma_staging, comorbidity, metastases, progress_report, treatment_setting, start_date, number_of_sessions, cost_per_session, 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. Oncology 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 oncology procedures. Most of the workflow's checks and validations are from the multisession validations.

4. Submit Oncology Preauth Request to SHA: If all validations pass, the system compiles the complete oncology 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 an oncology pre-authorisation request. Most of these checks stem from the specific multisession validations.

2.3. Workflow Data Dictionary

This table outlines the key information used and produced by this workflow:

Field Name	Description	Required (Input)	Type	Options (if applicable)	Purpose
consent_token	The consent token for the patient visit.	Yes	string		Authorizes the preauth request for the correct patient and active visit.
intervention_code	The unique identifier for the oncology intervention you 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.	Yes	string		Specifies the particular oncology procedure or treatment for which pre-authorization is being sought.
is_co_insured	Is the patient co-insured?	No	boolean		Indicates if the patient has co-insurance.
carcinoma_staging	The Carcinoma staging.	Yes	string	Stage 1, Stage 2, Stage 3, Stage 4	Provides details on the stage of carcinoma, essential for oncology treatment planning.
comorbidity	The comorbidity.	Yes	string		Describes any co-existing medical conditions.
metastases	The metastases.	Yes	string	Lung, Brain, Liver, Other (specify missing option)	Indicates the location of cancer spread.
progress_report	The patient's progress report.	No	string		Provides an update on the patient's condition and treatment progress.
treatment_setting	The treatment setting.	Yes	string	Day ward, Reclining chair, Side room (Specify your option)	Specifies where the treatment will take place.
start_date	The expected start date.	Yes	An ISO 8601 timestamp of the date for the		Marks the beginning of the authorized treatment period.
number_of_sessions	The number of sessions.	Yes	integer		Defines the extent of the oncology treatment plan (e.g., number of chemotherapy cycles).
cost_per_session	The cost per session.	Yes	float (up-to 2dp)		Specifies the cost for each individual session.
doctors	The Attending Doctors/Clinical Officers consent. This is an array of the doctors you need approval from.	Yes	array		Captures the medical professional(s) providing consent and oversight for the requested oncology service.
items	This will be an array of items in the preauth request.	Yes	array		Details the specific components of the oncology service being requested for authorization, crucial for financial assessment.
diagnoses	This will be an array of diagnoses in the preauth request.	Yes	array		Provides the medical justification for the requested oncology intervention, a fundamental requirement for SHA's review.
attachments	This will be an array of attachments in the request.	No	array		Provides essential clinical evidence or justification for SHA's detailed review of oncology procedures.

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

2.3.1. Preauth Doctor

This defines the structure for doctors associated with a preauth request.

Field Name	Info	Options (if applicable)	Is required?	Type
identification_number	The unique id to the doctor.		True	file
identification_type	The type of ID being used.	registration_number, National ID, Alien ID, Refugee ID	True	string
regulation_body	The licensing body choices. Defaults to KMPDC.	KMPDC, COC, NCK	True	string
intervention_code	The intervention code.		True	string
name	The client registry ID from the previous eligibility call.		True	string

2.3.2. Preauth Items

This defines the structure for individual items included in a preauth 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 to 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 defines the structure for diagnoses associated with a preauth request.

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

2.3.4. Preauth Attachments

This defines the structure for attachments included in a preauth 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