Claim - PreAuthorization link

1

Hi all,

Usually in insurance logic one claim will be submitted for one or more pre-authorization and usually a verification done on payer side to validate that submitted claim actually matching what already authorized, could you please suggest how to link submitted claim with it’s pre-authorization ? I noticed “related” field in claim request, can i use it for this purpose ?

Regards

2

Yes, though the set of relationship codes is not that great (and also isn’t very tight). You might submit a change request seeking improvement

1 Like
3

NO, the prior authorization references from an insurer would go in Claim.insurance.preAuthRef.

4

Please i need clarification how this flow will work in fhir since i understood preAuthRef in another way :

  • Patient submitted pre-authorizaiton (claim.use = Preauthorization)
  • Insurer checked patient plan & found that requested service need prior approval
  • Insurer will submit ClaimResponse with adjudication that this item need prior approval (to notify provider)
  • Patient will phone insurer and get preAuthRef (code) and submit new pre-authorization (claim.use Preauthorization) with provided code in Claim.insurance.preAuthRef
  • Insurer will verify provided preAuthRef & respond with needed adjudication (approval)
  • Provider submit claim for already approved pre-authorization to get his money (here how insurer will know this claim related to which pre-authorization in order to match them) ??

Regards