- 1. Pre-Authorisation (Prior Approval)
- Required for specific procedures, tests, or treatments
- Ensures the service is medically necessary and covered by the insurance plan
- Must be obtained before the service is rendered to avoid claim denial
- 2. Referral Process
- Involves a primary care physician directing the patient to a specialist or facility
- Common in HMO or managed care plans where gatekeeping is required
- Helps coordinate care and maintain continuity
- 3. Insurance Plan Requirements
- Each insurer has its own list of services requiring pre-authorisation or referral
- May vary based on policy type, provider network, and service category
- 4. Documentation & Submission
- Includes clinical notes, diagnosis codes, and treatment plans
- Submitted electronically or via fax to the insurance provider
- 5. Approval Timeline & Tracking
- Can take hours to days depending on urgency and insurer response
- Must be tracked to ensure timely scheduling and avoid delays
- 6. Impact on Billing & Claims
- Lack of pre-authorisation or referral may result in denied claims or out-of-pocket costs
- Proper documentation supports clean claim submission and reimbursement
- 7. Patient Communication
- Patients should be informed about requirements and potential delays
- Helps manage expectations and financial responsibility

Would you like this formatted into a checklist, SOP, or embedded into a patient registration template? I can also tailor it for specialty clinics or auto industry health programs if needed.