Question

1. Outline managed care requirements for patient referral?
2. Describe processes for:
   1. a) verification of eligibility for services
   2. b) precertification
   3. c.) preauthorization

Answer 1

ans;

a)Healthcare Insurance Eligibility Verification. ... The process of obtaining the insurance eligibility verification of a patient is necessary to insure that the patient has coverage, services that are being provided are covered, denials and appeals can be minimized and payments are expedited at the appropriate rates.

the insurance eligibility verification here as follows,

• Demographic information of the patient is collected from referral sources such as hospital or clinic or from the patient directly.
• Verification of the information obtained with the carrier. This service includes verification of:
  • payable benefits
  • co-pays
  • co-insurances
  • deductibles
  • patient policy status
  • effective date
  • type of plan and coverage details
  • plan exclusions
  • specific coverage
  • claims mailing address
  • referrals and pre-authorizations
  • maximum life time
• Verification of the patient's coverage on primary and secondary payers
• Patient's account updation.
• Properly completing the paperwork and communicating with the patient.

b.Precertification

• Pre-certification number is obtained when needed for the procedure treatment, visit or for any procedure.Completing appropriate criteria sheets and forms
• For the approval for the patient's authorization request,contacts the insurance companies on the physician’s behalf
• Once the forms are filed either online or via a web portal, then the specialist will follow up until authorization is received.
• If any further documents are necessary we will coordinate that with our client.

c. preauthorization.

Pre-authorization is a process by which the insured patient obtain approval for medical procedures or any kind of treatment from GBG/TieCare International before starting the proposed medical treatment.

The Pre-authorization process is commenced by viewing the www.gbg.com and completing the online Pre-authorization form. The initial exam or diagnostic reports that supports the medical aid for the request should be submitted through online. supplementary forms could result in the delay of your authorization. All health care and medical notes and information should be submitted with the preauthorization form. Depending on the complexity of the service being requested, additional information may be required, such as medical notes, information on prior treatment and clarification on the type of service to be provided. if there is any failure in submitting the form, there will be delay in the process and service may not get approved.