Why Does Pre-Authorisation Matter in Medical Billing?

Healthcare in 2026 has changed from what it was a few decades ago. Earlier, if one had health insurance, they usually paid the bills first and claimed the amount from the insurer later. Nowadays, the healthcare system has become more accessible and systematic.

One such aspect that makes the claim process easier for all parties involved is the pre-authorisation process. For the uninitiated, pre-authorisation in medical billing refers to the process of checking if a medical service is necessary, and whether it can be covered under the policy. Once this approval is received, the policyholder can go ahead with the treatment covered under the plan. One can use online pre-auth and claims tools to make the process faster.

First, let’s understand what pre-authorisation is. 

It is a process where the healthcare provider reaches out to the insurer to get clarity on the coverage of a particular treatment. In some cases, this may result in delays. However, it is usually not practiced during medical emergencies. Pre-authorisation is usually required for planned hospitalisation and elective procedures (non-emergency procedures). 

Pre-authorisation may also be required for costly care or uncommon medications, as they need closer examination. 

This process guarantees the efficient use of health funds. It allows the insurer to check if the medical procedure being undertaken is mandatory. 

The pre-authorisation medical billing team sends evidence to show that this particular treatment/care is the right choice for the patient.

Here’s a list of the types of treatments/medical-related aspects that may need pre-authorisation:

• Expensive drugs for rare health conditions.
• Medications that may have negative effects or come with safety risks.
• New medical tools that are not yet standard.
• Care that might be for aesthetic reasons rather than for health.
• Long-term nursing care at home.

There are ways to ease the pre-auth process. Using online preauth and claim management tools can allow the hospital to be sure about the payment. It also protects the insured member from getting a hefty bill after the treatment is over.

There is a clear connection between receiving approval and receiving payment. If a procedure needs a check but the hospital starts without it, the claim will likely fail. This is why online preauth and claims systems are so important for hospitals today. They keep a clear record of the permission from the insurance firm.

However, even with the pre-auth received, it is important to keep certain points in mind: 

List the Approval Number

When the bill goes to the insurance firm, it must have the approval number. This number is like a key that lets the payment go through. If this number is not there, the system might block the claim. 

Get Permission Early

Time is a big factor in medical billing. Except for life-saving emergencies, the request for a check must happen before the operation. An official from the insurance firm looks at the files to make a decision. Getting this approval means the person does not have to pay a large amount from their own pockets.

Ensure the Whole Care is Covered

Sometimes a doctor asks for three days in a bed, but the patient may need five. The team must update the pre-authorisation details in medical billing to cover the extra time. If only part of the stay is approved, the insurer will only pay for those specific days. Clear communication between the hospital and the insurer is crucial in this regard.

The work of pre-authorisation in medical billing is a key part of healthcare today. It ensures that care is necessary and fits the policy rules. Using modern tools for online pre-auth and claims helps hospitals work better. This lowers the likelihood of denied claims and maintains transparency between the insurer, the doctor, and the policyholder.

For strong financial protection against medical bills, consider opting for a health insurance plan from SBI General Insurance. Their extensive network helps make the approval and claim process easy and fast. Visit the website or download the SBIG app to find a health insurance cover that protects your future today.

1: What if the request is denied?

The doctor can send more papers to explain why the care is needed. An appeal can be made to the firm to look at the case again.

2: Does approval mean the bill is paid for sure?

It is a strong sign but not a total promise. The final bill must match what was approved. If the treatment changes, the insurer might want to look at the bill again.

3: How long does it take?

It can depend on the urgency of the treatment, the location, the policy coverage, and other factors. In 2026, online pre-auth and claim management systems are expected to process non-urgent requests in 7 days and urgent requests in 72 hours.

4: Is it needed for emergencies?

No, in an emergency, one can directly receive the treatment. Most rules allow the hospital to tell the firm within a day or two after the person arrives.

5: Who gets the approval?

The hospital or doctor's office usually does this work. They have the medical files needed by the insurer. But a patient should always ask if the pre-auth process has been completed before the treatment starts.