1) INTRODUCTION
There are four categories of preauthorization and claim procedures covered in these guidelines:
Medical Treatments
Surgical Treatments
Day Care Treatments
Follow-up Care
Guidelines for Preauthorization of Medical Package:
i) Patient admitted for IPD under medical packages.
ii) Preauthorization should be raised on the day of admission.
iii) If failed to do so, backdating can be done for 5 days for medical packages and 3 days for private hospitals.
iv) Preauthorization should not be done on the date of discharge.
v) Clinical notes detailing history and admission notes showing vitals and examination findings; any investigations done; and the planned line of management should be submitted during preauthorization.
vi) The first day is auto-approved.
vii) Enhancement should be raised 24 hours after the initial preauthorization.
viii) During enhancement, all up-to-date supporting documents such as clinical notes, including doctor’s progress notes, nurse’s notes, drug chart, etc., should be submitted.
ix) Enhancement should be done as per the ALOS of the patient.
x) If extra LOS is blocked, it can be reduced before claim submission.
3) Guidelines for Preauthorization for Surgical Cases:
i) Patient admitted for IPD for a surgical package.
ii) For elective/planned surgery, the EHCP should raise preauthorization before surgery. If they fail due to technical issues, Aadhaar card not linked, internet issues, etc., they should intimate the IC and SNA within 3 days for private hospitals and 5 days for public hospitals. If there is no intimation within the said period, the case should be blocked under Unspecified Medical Management.
iii) Preauthorization should not be done on the date of discharge.
iv) For emergency cases, preauthorization can be raised after surgery but not on the day of discharge.
v) During preauthorization, clinical notes and investigation reports should be submitted.
vi) For multiple surgical procedures in one OT session, the procedure with the highest rate shall be reimbursed at 100%, the second surgical procedure at 50% of the package rate, and the third and subsequent procedures at 25% of the package rate.
4) Guidelines for Preauthorization of Daycare:
i) Patient admitted under a daycare package.
ii) Clinical notes should be submitted during preauthorization.
iii) Preauthorization should be raised on the same day.
5) Guidelines for Preauthorization of Follow-up Care:
i) Patient admitted under a follow-up care package.
ii) Clinical notes and the earlier discharge summary should be submitted during preauthorization.
CLAIM SUBMISSION
1) Guidelines for Claim Submission of Medical Packages:
i) Carefully check if the LOS blocked in the TMS matches the LOS in the clinical documents before claim submission.
ii) One-day hospitalization should complete 24 hours.
iii) During claim submission, detailed ICPs, treatment details, detailed discharge summary, and all investigation reports should be submitted.
iv) Claims should be submitted within 30 days from the date of discharge.
2) Guidelines for Claim Submission of Surgical Packages:
i) During claim submission, all required documents as per HBP should be submitted, such as OT notes, pre-diagnostic reports, post-diagnostic reports, and discharge summary, as applicable.
ii) Claims should be submitted within 30 days from the date of discharge.
3) Guidelines for Claim Submission of Daycare and Follow-up Packages:
i) During claim submission, all required documents as per HBP should be submitted.
ii) Claims should be submitted within 30 days from the date of discharge.
