Approval Officer

Job Description

The main responsibility of the insurance department is to process pre-approvals from the In-network insurance companies, so that the patient’s can avail cashless treatment for the approved services.

Direct Billing: Cashless treatment given to patient with or without taking the approval form the In-network insurance companies. The charges will be later claimed from the insurance by the claims department.

Cash & Reimbursement: Patient’s belonging to out of network insurance companies need to pay the cash and later get it reimbursed from the insurance companies with a claim form filled by the doctor.

Pre-Approval: It is a guarantee of payment or a “go ahead” given by the In-network insurance companies to the hospitals for rendering the direct billing (cashless) facility to the patient’s for the approved services.

Pre-approval is requested from the insurance in the following scenarios:

• If the cash limit (given by the insurance) is exceeded – Refer handbook,
• If the service falls under the list of services which requires pre-approval– Refer handbook ,
  All IP and daycare cases.

Query: When the data provided to the insurance is insufficient, they send us in a form of query which needs to be replied by the treating doctor with his/her sign and seal.

Rejections: The insurance will reject services which falls under general exclusions, If the benefits are exhausted and if the services are not medically justified.

Reconsideration : Once the service is rejected by the insurance company, the treating doctor can appeal the decision by writing a justification/reconsideration request.

General Exclusions: Certain services under each insurance company are excluded and the payment related to these services are to be borne by the patient.

Ex: Infertility, Chronic conditions etc.

Out-Patient services [OP] : Services without hospitalization

Day-care/ Day-case: Ambulatory services or procedures with less than or equal to 12 hours of stay.

In-Patient: Services or procedures requiring more than 12 hours of stay.

Benefits: Each insurance policy has variable benefits, High-end cards with the maximum benefits and Basic card with less benefits, Benefits are denoted on the cards as OP: Outpatient; IP: In-patient; DN: Dental; MB: Maternity etc.

Patient responsibility: A part of the total bill is to be shared by the member Known as patzient responsibilty.

Example: Copay/Deductible: An upfront fixed amount applied on consultation & Coinsurance : % share on the bill.

DEPARTMENT WORK FLOW: A day in Insurance Department

The below flow chart explains day to day activities performed by the team member:

IP LIST

It is a report pulled from HIS [Hospital Information System], which gives the list of current admission at that particular time.

Our responsibility is to make sure that the patient’s admitted under insurance have approvals for in-patient services until that time, If the approval is not there need to request documents from ward for extension etc.

The IP List is prepared at 3 different times at-least with continuous updates as and when we receive any information from the ward or the doctors.

First at 8 am, as soon as the morning duty staff logs in, then at 1 pm, by the employee on afternoon duty and at 7 pm. A copy needs to be handed over to PRO at 7 PM and if any approval is not there, need to inform PRO, Ward & Billing Team

Following steps shows how to prepare an IP list:

• Login to HIS,
• From the tabs select REPORTS,
• Then click on favorite reports,
• Select IP LIST from the line items and then,
• Click on CSV, a dialogue box will open, select “open” to view the list in excel format.

Once the sheet is ready format the sheet with the required field, update the list by comparing the approvals received [from the shared folder]

Then call ward to check the status of patient, Example: For discharge, requires extension etc, and update in the sheet using the following abbreviations:

A: Approved

P : Private or Cash patients

*: Needs approval or extension

D: Discharged

4D: For discharge

WA: Waiting for approval

Sometimes if the patient is admitted in the late night, there will only be a verbal approval taken by the ER doctors, we need to Clear the IP’s first by requesting claim form and card copy form the ward before moving on the OP requests and follow up’s.

OP REQUESTS

Approval requests for the services intended to be done on OP basis

Once the request is received follow the below steps:

Documents Required: Claim Form & card copy

• Check whether the claim form is the right one,
• Check if the services which requires approval are mentioned on a separate post it with CPT codes and their prices.
• Send the claim to coders for code confirmation and take their signature.
• Once the codes are confirmed, verify the price for each CPT code from the CPT PRICELIST – in Shared Folder.
• If the request is from Dental department need to write the correct tooth# and refer CDT list for the price.
• Then Send the approval request to the insurance company by any of the following method as specified by the insurance [A separate list is provided with the specification]

E-mail: By simply emailing the request to the address present in the handbook. Example for Amity, Mednet, Al Buhairs, Al Dhafra, Oman etc.

Once send, need to document the date, time and system name from which the request is send.

Online System: By entering the request on the online portal [Steps on how to enter will be explained in practical]. Example for Nas, Nextcare etc.

Need to write reference # generated automatically with date and time.

Fax: Some insurances requires the request to be faxed. Example: Adnic, Daman etc.

Need to attach fax confirmation.

Verbal Approval: Certain insurance allow us to take a verbal approval by calling them for emergency services. Once the verbal approval is there the patient can avail the services, subsequently we need to send the request for written approval.

Important : Need to note the name of the person who gave approval, verbal code[if any], date, time and the services approved.

After sending the request, need to place the copy in the designated trays for each insurance company

IP REQUESTS

Requests for the services which requires admission. Below are the steps involved in processing the IP requests:

Documents Required: For new encounter: Claim form, Medical Report (If any), Lab & Radiology Reports (if Any) & card copy.

For Extension: Approval copy, Medical Report, Lab & Radiology reports, Drug & Fluid Charts and vitals.

For Revisions: Medical Report, OT notes(for surgeries), Final Bill (Revision of costs) & Discharge summary( For Discharge approvals)

• Check whether the claim is the right one,
• Check if the services which requires approval are mentioned on a separate post it,
• If for medical management, number of days should be mentioned,
• And, if the request is for a surgery, CPT codes, Anesthesia Code, OT Hours, No. Of days should be present.
• For surgery request send the claim for code confirmation,
• Prepare the cost estimate using the PRICELIST. [Cost estimate template will be shared],
• Send the requests using the similar steps as discussed in OP requests.

QUERIES:

For both OP and IP requests, if the information given to the insurance company is insufficient, the insurance company will send us a query requesting the required information.

The same should be send to the concerned staff for the reply from the treating doctor.

The reply received should be sent to the insurance again for processing.

REJECTIONS / RECONSIDERATION:

Services can be rejected if they fall under general exclusions or if they are not medically justified.

Treating doctors can appeal the decision of the insurer by writing the justification or Reconsideration .

FOLLOW UP:

After receiving the approval requests, the insurance companies will take 24 – 48 hours for processing, but we need to follow up with them on a frequent intervals so as to the status of the request [Received, under process, pending with Payer etc]. This can be done by simply calling them.

Insurance who have online systems have a low TAT, so we can simply check the status online.

In case, the response is delayed we need to send reminder to the companies in order to get the request approved.

APPROVAL LOGS AND DISPATCHING

Once we get any response (approval, query or rejections) from the insurance, either by mail, fax or online system. Need to save a copy in the shared folder under the treating doctor’s names.

COMPUTER => INSURANCE Shared Folder => APPROVAL STATUS => DOCTORS FOLDER

Then, take a print and update the details in the APPROVAL LOGS – Shared Folder

Before dispatching we need to check the below check list and if anything is incorrect or missing, need to send the approval for revision

The main responsibility of the insurance department is to process pre-approvals from the In-network insurance companies, so that the patient’s can avail cashless treatment for the approved services.

 Direct Billing: Cashless treatment given to patient with or without taking the approval form the In-network insurance companies. The charges will be later claimed from the insurance by the claims department.

Cash & Reimbursement: Patient’s belonging to out of network insurance companies need to pay the cash and later get it reimbursed from the insurance companies with a claim form filled by the doctor.

Pre-Approval: It is a guarantee of payment or a “go ahead” given by the In-network insurance companies to the hospitals for rendering the direct billing (cashless) facility to the patient’s for the approved services.

Pre-approval is requested from the insurance in the following scenarios:

• If the cash limit (given by the insurance) is exceeded – Refer handbook,
• If the service falls under the list of services which requires pre-approval– Refer handbook ,
  All IP and daycare cases.

Query: When the data provided to the insurance is insufficient, they send us in a form of query which needs to be replied by the treating doctor with his/her sign and seal.

Rejections: The insurance will reject services which falls under general exclusions, If the benefits are exhausted and if the services are not medically justified.

Reconsideration : Once the service is rejected by the insurance company, the treating doctor can appeal the decision by writing a justification/reconsideration request.

General Exclusions: Certain services under each insurance company are excluded and the payment related to these services are to be borne by the patient.

Ex: Infertility, Chronic conditions etc.

Out-Patient services [OP] : Services without hospitalization

Out-Patient services [OP] : Services without hospitalization

In-Patient: Services or procedures requiring more than 12 hours of stay.

Benefits: Each insurance policy has variable benefits, High-end cards with the maximum benefits and Basic card with less benefits, Benefits are denoted on the cards as OP: Outpatient; IP: In-patient; DN: Dental; MB: Maternity etc.

Patient responsibility: A part of the total bill is to be shared by the member Known as patzient responsibilty.

Example: Copay/Deductible: An upfront fixed amount applied on consultation & Coinsurance : % share on the bill.

 DEPARTMENT WORK FLOW: A day in Insurance Department

The below flow chart explains day to day activities performed by the team member:

IP LIST

It is a report pulled from HIS [Hospital Information System], which gives the list of current admission at that particular time.

Our responsibility is to make sure that the patient’s admitted under insurance have approvals for in-patient services until that time, If the approval is not there need to request documents from ward for extension etc.

The IP List is prepared at 3 different times at-least with continuous updates as and when we receive any information from the ward or the doctors.

First at 8 am, as soon as the morning duty staff logs in, then at 1 pm, by the employee on afternoon duty and at 7 pm. A copy needs to be handed over to PRO at 7 PM and if any approval is not there, need to inform PRO, Ward & Billing Team

Following steps shows how to prepare an IP list:

• Login to HIS,
• From the tabs select REPORTS,
• Then click on favorite reports,
• Select IP LIST from the line items and then,
• Click on CSV, a dialogue box will open, select “open” to view the list in excel format.

Once the sheet is ready format the sheet with the required field, update the list by comparing the approvals received [from the shared folder]

Then call ward to check the status of patient, Example: For discharge, requires extension etc, and update in the sheet using the following abbreviations:

A: Approved

P : Private or Cash patients

*: Needs approval or extension

D: Discharged

4D: For discharge

WA: Waiting for approval

Sometimes if the patient is admitted in the late night, there will only be a verbal approval taken by the ER doctors, we need to Clear the IP’s first by requesting claim form and card copy form the ward before moving on the OP requests and follow up’s.

OP REQUESTS

Approval requests for the services intended to be done on OP basis

Once the request is received follow the below steps:

Documents Required:

• Check whether the claim form is the right one,
• Check if the services which requires approval are mentioned on a separate post it with CPT codes and their prices.
• Send the claim to coders for code confirmation and take their signature.
• Once the codes are confirmed, verify the price for each CPT code from the CPT PRICELIST – in Shared Folder.
  If the request is from Dental department need to write the correct tooth# and refer CDT list for the price.
  Then Send the approval request to the insurance company by any of the following method as specified by the insurance [A separate list is provided with the specification]

E-mail: By simply emailing the request to the address present in the handbook. Example for Amity, Mednet, Al Buhairs, Al Dhafra, Oman etc.

Once send, need to document the date, time and system name from which the request is send.

Online System: By entering the request on the online portal [Steps on how to enter will be explained in practical]. Example for Nas, Nextcare etc.

Need to write reference # generated automatically with date and time.

Fax: Some insurances requires the request to be faxed. Example: Adnic, Daman etc.

Need to attach fax confirmation.

Verbal Approval: Certain insurance allow us to take a verbal approval by calling them for emergency services. Once the verbal approval is there the patient can avail the services, subsequently we need to send the request for written approval.

Important : Need to note the name of the person who gave approval, verbal code[if any], date, time and the services approved.

After sending the request, need to place the copy in the designated trays for each insurance company

IP REQUESTS

Requests for the services which requires admission. Below are the steps involved in processing the IP requests:

Documents Required: For new encounter: Claim form, Medical Report (If any), Lab & Radiology Reports (if Any) & card copy.

For Extension: Approval copy, Medical Report, Lab & Radiology reports, Drug & Fluid Charts and vitals.

For Revisions: Medical Report, OT notes(for surgeries), Final Bill (Revision of costs) & Discharge summary( For Discharge approvals)

• Check whether the claim is the right one,
• Check if the services which requires approval are mentioned on a separate post it,
• If for medical management, number of days should be mentioned,
• And, if the request is for a surgery, CPT codes, Anesthesia Code, OT Hours, No. Of days should be present.
• For surgery request send the claim for code confirmation,
• Prepare the cost estimate using the PRICELIST. [Cost estimate template will be shared],
• Send the requests using the similar steps as discussed in OP requests.

QUERIES:

For both OP and IP requests, if the information given to the insurance company is insufficient, the insurance company will send us a query requesting the required information.

The same should be send to the concerned staff for the reply from the treating doctor.

The reply received should be sent to the insurance again for processing.

REJECTIONS / RECONSIDERATION:

Services can be rejected if they fall under general exclusions or if they are not medically justified.

Treating doctors can appeal the decision of the insurer by writing the justification or Reconsideration .

FOLLOW UP:

After receiving the approval requests, the insurance companies will take 24 – 48 hours for processing, but we need to follow up with them on a frequent intervals so as to the status of the request [Received, under process, pending with Payer etc]. This can be done by simply calling them.

Insurance who have online systems have a low TAT, so we can simply check the status online.

In case, the response is delayed we need to send reminder to the companies in order to get the request approved.

APPROVAL LOGS AND DISPATCHING

Once we get any response (approval, query or rejections) from the insurance, either by mail, fax or online system. Need to save a copy in the shared folder under the treating doctor’s names.

COMPUTER => INSURANCE Shared Folder => APPROVAL STATUS => DOCTORS FOLDER

Then, take a print and update the details in the APPROVAL LOGS – Shared Folder

Before dispatching we need to check the below check list and if anything is incorrect or missing, need to send the approval for revision
Equivalent to the position