Pre-Authorization

Pre-authorization

  1. The Aarogyasri Health Care Trust shall receive all the pre-authorization requests from NWHs, scrutinize them as per guidelines issued by the AHCT from time to time with the help of medical professionals and accord final approval within 12 hours of submission of request by NWH.
  2. A query on an incomplete pre-authorization request can be raised not more than once by the panel doctor. In case of a query by panel doctor, an additional time of 6 hours will be allowed to the Aarogyasri Health Care Trust so as to enable to offer final approval within 18 hours.
  3. Wherever required the services of necessary specialists shall be utilized by the Aarogyasri Health Care Trust to evaluate special cases.
  4. The responsibility & liability of management of a case solely rests with the treating doctor and the NWH. The pre-authorization remarks of panel doctor or Aarogyasri Health Care Trust shall be construed as advisory in nature and shall not in any way alter the line of treatment proposed by the treating doctor.
  5. No recommendation for reduction in package price shall be made at pre-authorization stage by the Aarogyasri Health Care Trust.
  6. Telephonic approval: The NWH shall obtain telephonic pre-authorization through dedicated telephone lines in all cases of emergencies. NWH shall only obtain a telephonic approval after confirming that the particular case falls within the purview of the scheme. A telephonic pre-authorization shall be deemed to be a provisional approval, and shall necessarily be followed by a regular pre-authorization within 72 hours.
  7. The rejection of pre-authorization by Aarogyasri Health Care Trust shall not be construed as refusal of treatment to the patient by the Aarogyasri Health Care Trust. The rejection of pre-authorization merely means the disease of the patient and treatment choices are out of the listed therapies.
  8. The approval of pre-authorization by the Aarogyasri Health Care Trust shall be based on online evidence of diagnosis and choice of treatment arrived at by the treating doctor. The approval by Aarogyasri Health Care Trust shall be deemed as an approval of the case for financial assistance under the scheme and shall not be construed as an endorsement of treatment by the NWH.
  9. Enhancement (Package Price Adjustment): The NWH shall provide end to end cashless services within the package. However NWH may apply for enhancement of the package price in case of exigencies prior to discharge as per Scheme guidelines.

24-Hour E-authorization

All pre-authorizations shall be handled by the Aarogyasri Health Care Trust through existing online e-authorization workflow. Aarogyasri Health Care Trust shall establish necessary IT infrastructure to handle additional load of pre-authorizations on account of scheme. The pre-authorization shall be done 24x7x365 days.

Scheme Technical Committee

A technical committee for the scheme, herein after called the scheme technical committee shall exercise the following powers of recommendation to the CEO:
  1. Final decision on pre-authorizations in case of difference of opinion.
  2. Authorization of utilization of buffer amountĀ.
  3. Authorization of package price enhancements or pricing for unlisted therapies to be paid from the buffer.
  4. Modification of nomenclature and relocation of any listed therapy.
  5. Minor changes in protocols for the listed therapies.
  6. Framing of guidelines and evolving objective criteria to assist proper selection of cases in order to reduce moral hazard.