Preauths Process Overview: Obtaining Prior Authorisation for Healthcare Services
1. Introduction: Understanding Pre-Authorisation
Welcome to the Preauths Process! This comprehensive guide provides a high-level overview of how our system facilitates the important step of obtaining prior authorisation for specific healthcare services.
Pre-authorisation is a key requirement for certain medical interventions, ensuring that the Social Health Authority (SHA) reviews and approves payment for a service before it is rendered to a patient.
The Preauthorisation Process is a series of workflows designed to facilitate the submission, review, and approval of requests for specialised or high-cost healthcare services. It involves submitting detailed medical information to the SHA for their assessment and decision, ultimately determining whether a patient's planned treatment will be covered.
1.1. Why This Full Process Matters
An accurate and thorough Pre-Auth process helps ensure financial coverage, compliance, and appropriate utilisation of healthcare services. It is crucial because it:
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Ensures Financial Coverage: Guarantees that high-cost, specialised, or planned interventions receive prior approval from SHA, providing financial assurance for both the patient and the healthcare facility.
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Prevents Claim Rejections: By obtaining pre-authorisation upfront, it significantly reduces the likelihood of claims being rejected by SHA due to a lack of prior approval, protecting the facility's revenue.
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Efficient use of medical funds: SHA's review process helps ensure that services are medically necessary and appropriate, contributing to the efficient use of healthcare funds and preventing unnecessary expenditures.
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Promotes Clinical Compliance: The requirement for detailed clinical information and the doctor's consent facilitates a review of the medical necessity of the proposed intervention, enhancing the quality of care.
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Streamlines Service Delivery: With pre-authorisation in place, facilities can proceed with planned treatments with confidence, minimising administrative delays and patient uncertainty regarding coverage.
2. The Preauths Process Journey: Step-by-Step Authorisation
The complete Preauths Process is a multi-step process, involving various types of requests and specialised forms. Each workflow within this process is designed to handle different scenarios for obtaining SHA approval.
Here are the key types of preauthorization requests and the associated workflows:
2.1. Step 1: Normal Preauths
This workflow handles the submission of a standard general preauthorization request for a single intervention or a set of related interventions that require prior approval from SHA.
It's the most common pathway for obtaining approval for a wide range of services, ensuring compliance with routine pre-authorised care.
2.2. Step 2: Multisession Preauths
This workflow facilitates the submission of a preauthorization request for interventions that require multiple sessions over a period (e.g., chemotherapy cycles, physical therapy courses). It streamlines the authorisation process for continuous care, allowing for approval of an entire treatment plan rather than individual sessions, which is critical for chronic conditions.
2.3. Step 3: Elective Preauthorization
This workflow manages the submission of preauthorization requests for elective procedures, which are planned and scheduled in advance. These preauthorizations involve obtaining approval before the patient's actual visit, ensuring that the procedures receive the necessary prior authorisation. This process allows patients and facilities to confirm financial coverage, enabling them to schedule and prepare accordingly.
2.4. Specialised Preauth Forms
Beyond the general request types, certain types of preauths have specific workflows for creating detailed records for specialised medical areas. These forms capture the unique clinical and service details required for SHA's review. These include:
- Surgical Preauth: For planned surgical procedures.
- Renal Preauth: For kidney-related treatments, often involving dialysis sessions.
- Oncology Preauth: For cancer diagnosis and treatment plans.
- Imaging Preauth: For specialised diagnostic imaging services (e.g., MRI, CT scans).
- Optical Preauth: For eye-related services, including consultations and optical items.
Note: Each of these specialised preauth forms serves as the detailed input for one of the various preauthorization request types (Normal, Multisession, Elective), depending on the nature of the service.
3. How Workflows Connect
While each workflow within the Preauths Process has a distinct role, they are deeply interconnected:
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Foundation from Eligibility & Intervention Coverage: The decision to initiate a preauth request typically stems from the Eligibility Process (identifying a patient's general coverage) and the Intervention Coverage Process (identifying specific services that require pre-authorisation).
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Consent Token Authorisation: All preauth requests utilise a
consent_tokenobtained from the Start Visit Process, ensuring that the preauthorization request is made within the context of an active, patient-consented visit. -
Detailed Clinical Data: Preauth workflows require comprehensive clinical information, diagnoses, and proposed items/interventions. This data is often prepared by clinical staff and forms the core of the preauthorization request.
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Doctor's Consent: Many preauth types explicitly require consent from attending doctors or clinical officers, ensuring medical oversight and accountability.
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Attachments: The ability to include supporting documents (attachments) is common across various preauth types, providing necessary evidence for SHA's review.
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Outcome Dictates Service Delivery: The outcome of a preauthorization (approved, rejected, or more info requested) directly dictates whether the proposed service can proceed and be covered by SHA. This outcome then influences subsequent steps in the patient's care journey and the facility's claiming process.