Preauthorization Doctor Consent

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Preauth Doctor Consent Process Overview: Facilitating Doctor Approval for Pre-Authorizations

1. Introduction: Understanding Preauth Doctor Consent

This guide covers the Doctor Consent process for pre-authorisations - specifically the fallback resend workflow triggered when a doctor needs the consent request to be re-delivered.

The Preauth Doctor Consent process, through the Doctor Consent workflow, is designed to ensure that all pre-authorisation requests submitted to the Social Health Authority (SHA) have the necessary medical approval from the attending doctor. It's about moving from a prepared pre-authorisation request to one that is officially verified by the responsible medical professional.

1.1. Why This Full Process Matters

The Preauth Doctor Consent process is fundamental to compliant and medically justified healthcare delivery. It is crucial because it:

• Ensures Medical Accountability: Verifies that a qualified medical professional reviews and approves the planned intervention.
• Validates Medical Necessity: Strengthens the medical justification for the pre-authorisation request, increasing the likelihood of SHA approval.
• Maintains Regulatory Compliance: Adheres to requirements that mandate doctors' consent for certain procedures and treatments.
• Prevents Claim Denials: Reduces the risk of pre-auth requests being denied due to missing or unverified medical consent.

1.2. Doctor Approval Status Flow

When a preauth for an intervention with needsDoctorAuthorization: true is created, it progresses through the following statuses:

Status	Description
PENDING_DOCTOR_APPROVAL	The preauth has been created and a consent request has been sent to the doctor. Awaiting the doctor's response.
ACTIVE	The doctor has approved the consent request. The preauth is submitted to the payer (SHA) for review.
FINALISED	SHA has reviewed and approved the preauth. The service can proceed with financial coverage.

1.3. How the request reaches the doctor

The consent request is delivered as:

• a two-way SMS the doctor can reply to,
• a request in the Practice360 app, or
• an email.

The doctor's response is received and processed automatically, and the preauth status is updated from it.

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2. The Full Preauth Doctor Consent Journey: Step-by-Step Doctor Approval

The complete Preauth Doctor Consent process is centred around the Doctor Consent workflow. This ensures medical approval is secured before a pre-authorisation can proceed.

2.1. Step 1: Doctor Consent Workflow

This foundational step involves prompting a consent request to be sent to the attending doctor on a preauth, and allowing them to approve or reject it.

This step is vital for ensuring every pre-authorisation request has explicit medical backing. Without the doctor’s consent, the preauth is incomplete and cannot be submitted to SHA.

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3. Workflow Details: Doctor Consent

3.1. Workflow Description: Step-by-Step System Behavior

When a preauth request requires doctor consent, here’s what happens:

1. Consent Prompt Initiation
   A request is triggered to send a consent prompt to the attending doctor.

2. Doctor and Facility Validation

   • Verify that the doctor exists in the health worker registry.
   • Check the facility’s registration and ability to transact.
   • Confirm the doctor has a valid KMPDC license.

3. Consent Request Delivery
   The system sends an SMS (and optionally email) to the doctor with preauth details and a consent prompt.

4. Doctor Response Reception
   The doctor responds via SMS (typically with a code) indicating approval or rejection.

5. Preauth Status Update
   Based on the response, the system updates the pre-authorisation request accordingly.

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3.2. Key Validations: Our System's Essential Checks

• Valid Doctor License (KMPDC)
  Only doctors with a valid license can consent.

• Doctor Existence in Registry
  The doctor must exist and be verifiable in the national health worker registry.

• Valid Facility
  The facility must be registered and authorized to transact.

• Consent Request Delivery
  The system must successfully send the SMS/email request to the doctor.

• Consent Response Handling
  The system must be able to receive and process the doctor's response (typically SMS).

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3.3. Expected Outcomes from this Workflow

• Success: Doctor Consent Approved
  The request is sent and the doctor approves. The preauth now includes medical consent and may proceed.

• Success: Doctor Consent Rejected
  The request is sent and the doctor rejects it. The preauth cannot continue and must be reviewed or cancelled.

• Failure: Invalid Doctor or Facility
  The doctor or facility ID is missing, unregistered, or unauthorized. The consent request is blocked until valid details are provided.

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3.4. Workflow Data Dictionary

This endpoint accepts the resend payload (ResendPreauthDoctorRequest). It carries the details needed to identify the preauth and the doctor, so a fresh consent request can be delivered.

Field Name	Info	Options (if applicable)	Is required?	Type
consent_token	The consent token for the patient visit.		True	string
intervention_code	The intervention code the doctor consent request applies to.		True	string
service_type	The service type for the encounter.	INPATIENT, OUTPATIENT	False	string
request_type	The request type. Fixed value PREAUTH_DOCTOR_APPROVAL_REQUEST.	PREAUTH_DOCTOR_APPROVAL_REQUEST	True	string
identification_type	The type of ID being used for the doctor.	registration_number, National ID, Alien ID, Refugee ID	True	string
identification_number	The doctor's identification number.		True	string
regulation_body	The doctor's licensing body.	KMPDC, COC, NCK, PPB	True	string
practitioner_registration_number	The doctor's practitioner registration number.		False	string

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4. Related Resources

• Intervention Coverage - where needsDoctorAuthorization comes from.
• Surgical Rules - the rule set that makes doctor approval mandatory for every surgical intervention.
• Normal Preauthorizations - creating the preauth that sends the first request.
• Elective Preauthorizations - the pre-visit path.
• Preauths Process Overview - how the preauth paths relate.
• Remove Preauth Doctor - changing who the request goes to.

5. Related Scenarios

• Scenario 3: SHIF IP FFS Elective Preauth
• Scenario 4: SHIF OP FFS Elective Preauth