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What Is Prior Authorisation for Health Insurance Policy?

When purchasing health insurance, customers often consider how quickly claims are resolved. The process of settling claims is multi-layered. Therefore, while insurance promises a speedy turnaround on claims processing, it doesn’t mean you’ll be able to leave the hospital with all your bills reimbursed. It merely denotes a prompt decision on whether the insurance company would accept the claim.

Prior authorisation refers to this phase of the cashless claims in health insurance. Some of the best health insurance policy come with this feature.

What kinds of medical procedures and drugs might demand prior consent?

  • Drugs that may be dangerous when mixed with other drugs
  • Alternatives to expensive but equally effective medical procedures
  • Medication and medical procedures that should only be used in specific medical situations
  • Medications and medical procedures that are frequently abused or misused
  • Substances that are frequently utilised for cosmetic effects

How do you get prior approval?

Your healthcare provider may start the prior authorisation procedure if they are a part of your insurer’s network.

You are responsible for securing prior permission if you choose to use a healthcare provider outside your insurance plan’s network. If you don’t get it, your insurance company might not pay for the therapy or medication, or you might have to pay more out of pocket.

To learn more about the procedures, services, and supplies that your particular policy needs for prior authorisation, consult your agent or give the number on your health plan ID card a call. If you are buying an online health insurance policy, then please confirm if this prior authorisation feature is available.

What is the process for obtaining prior authorisation?

Prior authorisation, or preliminary authorisation, is the stage of claims approval where the insurer informs the hospital of whether or not the claim is admissible. With assistance from your attending physician and the hospital, you fill out a prior authorisation form to initiate the process. The form is sent to the insurance together with any pertinent paperwork and price information.

To approve the claim, the insurer examines them. This could take a whole day or just an hour, depending on the quoted turnaround time of the various insurance. The evaluation procedure used by insurers also affects how long it takes. The policyholder is then admitted, and treatment starts.

Hospitals may occasionally request a deposit when there is an emergency. When an unexpected situation occurs, admission may not be possible while waiting for prior authorisation from the insurance company. However, the hospital may return the deposit later. It is therefore better to do a health insurance policy comparison at the time of purchase, to understand all policy features.

The discharge is the last step in the claims approval process. The insurer receives a discharge statement along with hospital expenses. The insurance examines the invoices and pays the hospital straight after doing so.

However, this is not so easy. The final claim typically goes through multiple stages of examination. The insurer could request more paperwork to ensure that invoicing was done correctly. All of this may delay the process of discharge.

It’s crucial to remember that prior authorisation of claims does not signify the insurer’s final acceptance or denial of the claim. The approval may be affected if the diagnosis changes as the treatment progresses. This implies that the claim might also be rejected if new information becomes available. Therefore, even if it’s encouraging to see insurers pre-approving quickly, it is not a guarantee of a final claims settlement.

Always put your family’s health and financial security first. Choosing the best health insurance policy keeps you worry-free as it covers a variety of medical expenses that are not just restricted to hospital care.

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

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