What Is Pre-Authorisation in Health Insurance?

When a planned medical treatment or hospitalisation is scheduled, pre-authorisation can make filing a claim easier. It plays a crucial role in cashless claims. Since the insurer reviews and approves your treatment in advance, you can seamlessly get a cashless claim settlement at the network hospital. Understanding how pre-authorisation in health insurance works helps you navigate the process seamlessly.

Pre-authorisation in health insurance is the approval taken from the insurer before a planned treatment or hospitalization. It confirms that the procedure is covered and helps avail cashless treatment at network hospitals. 

Key Takeaways: 

• Pre-authorisation is the insurer’s way of reviewing and approving planned treatment to enable cashless claims at network hospitals.
• It is typically required for all cashless hospitalisation at a network hospital.
• The process involves submitting treatment details and documents to the hospital or TPA (Third-Party Administrator) for evaluation.
• Pre-authorisation and reimbursement differ in terms of timing, payment method, approval timelines, and effort required.

• Delays and rejections usually result from incomplete documents, non-alignment with medical necessity, or failure to qualify under policy terms. 

   

Certain planned and high-cost procedures require health insurance pre-authorisation for the cashless claim process. The prior approval confirms medical necessity and coverage under the policy. 

Here are some of the common medications and procedures requiring prior authorisation in health insurance: 

• Any non-emergency surgery or day care procedure like knee/hip replacement, cataract surgery, minimally invasive cardiac procedures, etc.
• Treatments involving MRI, CT scans, PET scans, endoscopic procedures, and the like.  
• Cancer therapies (chemotherapy, radiation), organ-related treatments, or advanced procedures usually require you to go through the health insurance pre-authorisation process.
• Expensive injectables, high-risk drugs, medication used for cosmetic reasons, etc., are often reviewed under pre-authorisation.  

If you’re seeking a planned treatment, you can undergo the following process to get pre-authorisation in health insurance and settle expenses through a cashless claim: 

1. Choose the Right Hospital 

Choose a network hospital that is covered for cashless health insurance by your policy provider. Check the list of hospitals partnered with under the policy on the app or insurer’s portal. 

2. Fill in the Pre-Authorisation Form 

Your doctor will provide you with treatment details to validate your pre-authorisation request. Fill in all the information accurately.   

3. Submit Documents 

Furnish documents supporting your treatment details as requested by your insurer or Third-Party Administrator (TPA). 

4. Wait for Insurer Review 

The insurance provider may approve the claim or request additional details to confirm the medical necessity and alignment of the treatment with the policy coverage. 

5. Receive Confirmation   

Once the verification is complete, you will receive a decision at the earliest. If approved, the hospital proceeds with the admission and your treatment goes through without the hassle of managing hospital bills. 

When you initiate a pre-authorisation request, network hospitals and TPAs are the two key touchpoints. Here’s how they contribute to the pre-authorisation process: 

• Network hospital 

The hospital within your insurer’s network collects your medical bills and helps you fill out the pre-authorisation form with relevant treatment details. They also respond to any insurer queries that can support your request. 

• TPA 

The TPA is an intermediary between the insurance company and the network hospital. They review documents, apply standard checks, and coordinate with the insurer to confirm your eligibility for cashless health insurance coverage.      

With some insurers, there may be no TPA. Claims may be handled entirely via in-house teams. 

Once you initiate your claim request, the pre-authorisation involves the submission of these crucial documents to support your case: 

• Pre-Authorisation Form: An accurately filled form with your personal information, proposed treatment, details of the hospital, etc.
• Doctor’s Recommendation: A detailed note from your doctor giving details of your diagnosis, treatment plan, and the medical relevance of the procedure.
• Medical Reports: Test results, prescriptions, and past records supporting the diagnosis.
• ID and Policy Details: Your health card, along with policy copy and a valid ID proof to verify your identity for coverage.
• Estimated Cost: A brief breakdown of expected expenses that the hospital provides for review. 

The network hospital will help you throughout the process of filling out the pre-authorisation form and submitting the relevant details for your treatment. 

Pre-authorisation in health insurance makes it easier to get your claim settled for planned treatments. Some of its key advantages include: 

• Enables cashless treatment at network hospitals where the insurer settles your claim directly.
• You get clear visibility on what is covered under the policy terms.
• It saves you from the hassle of upfront costs.
• The admission process is smoother because most approvals are handled in advance. 

• Reduced chances of claim rejection due to prior validation of your treatment. 

   

Both systems pertain to raising a health insurance claim, but help process it differently. Here’s a brief comparison of the two to help you see the difference clearly: 

While the pre-authorisation process is streamlined, a few inconsistencies can lead to rejection or delays. Some of the common reasons include: 

• Incomplete or missing medical details
• Lack of clear medical necessity for the treatment
• Treatment not aligning with the policy inclusions or waiting periods
• Errors or mismatches in patient, policy, or hospital details
• Request raised at a non-network hospital
• Treatment opted for at an excluded hospital

• Delayed submission of the pre-authorisation form before admission. 

   

When you know what to expect, getting the medical care you need becomes easier. Pre-authorisation in health insurance is meant to make this easier. It ensures your cashless claim is processed smoothly. As your treatment details are validated in advance, your bills are settled without intervention during your hospitalisation. It’s an important factor to consider when buying health insurance online.  

Consider renowned policy providers like SBI General Insurance for a streamlined process meeting the IRDAI guidelines. You can also experience similar efficiency with other policies, such as car insurance and bike insurance. 

1. Is pre-authorisation mandatory for all health insurance claims? 

No, it is particularly needed for planned treatments and cashless claims. 

2. What is the difference between pre-authorisation and reimbursement claims? 

Pre-authorisation is required before treatment for cashless settlement.  Reimbursement, on the other hand, involves paying first and claiming later. 

3. How long does pre-authorisation approval take? 

Pre-authorisation typically takes a few hours to a couple of days for approval. This is based on the treatment and the accuracy of details. 

4. Can pre-authorisation be denied by the insurer? 

Yes, it can be denied if the treatment does not qualify as per the policy coverage. 

5. What documents are required for pre-authorisation? 

You generally need a pre-authorisation form, a doctor’s recommendation, medical reports, ID and policy details, and a cost estimate. 

6. Is pre-authorisation required for emergency hospitalisation? 

No, in emergencies, you can get treated immediately and seek approval later during the hospitalisation period.  

7. What happens if pre-authorisation is not taken? 

You may need to file a reimbursement claim upfront, subject to policy terms and approval.