Preauthorizations

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Preauths Process Guide: Surgical Preauth Workflow

1. Overview: Obtaining Prior Authorization for Surgical Procedures

This guide details the Surgical Preauth Workflow, a specialized preauth form which is part of the broader Preauths Process. This workflow is specifically designed to facilitate the submission of pre-authorization requests for surgical interventions that require prior approval from the Social Health Authority (SHA) for payment.

A surgical preauth can be a normal OR an elective preauth, since a surgical procedure may be elective or not. This workflow ensures that planned surgical procedures receive the necessary prior approval, providing financial assurance and regulatory compliance before the operation takes place.

2. Workflow Details: Submitting a Surgical Preauth

This section details the step-by-step process for submitting a surgical pre-authorization request.

2.1. Step-by-Step System Behavior

1. Input Reception: The system receives the consent_token for the patient's active visit, the intervention_code for the surgical procedure, arrays of items, diagnoses, doctors, attachments, and specific surgical details like surgery_date, chief_complaint, vital_signs, history_of_present_illness, physical_examination, investigation_report_details, type_of_anaesthesia, is_condition_related_to_employment, is_condition_related_to_auto_or_other_accident, is_co_insured, and co_insurance_details.

2. Authorization and Visit Context Check: The system uses the provided consent_token to validate that the patient has a valid, active visit and that consent is still active. This also includes confirming the patient is in an active state.

3. Surgical Preauth Request Validation: The system performs comprehensive and specific checks on the incoming data and the context of the request, as per SHA's rules for surgical procedures. A surgical preauth can be normal or elective, so the applicable normal or elective preauth validations are considered depending on the intervention. On top of these, specific Surgical Form Field Validations are checked such as surgery_date, chief_complaint, vital_signs, history_of_present_illness, physical_examination, investigation_report_details, and type_of_anaesthesia.

4. Submit Surgical Preauth Request to SHA: If all validations pass, the system compiles the complete surgical pre-authorization request payload and submits it to SHA's preauth service.

5. Receive SHA Response: The system receives and processes the response from SHA, which indicates the submission status (e.g., success, failure, pending review).

2.2. Key Validations

These are the critical checks performed during this workflow to ensure the accurate and compliant submission of a surgical pre-authorisation request. Because a surgical preauth can be either a normal or an elective preauth, it inherits the validation rules of whichever type applies to the intervention - the normal preauth validations when the surgery is not elective, and the elective preauth validations when it is - in addition to the surgical form field checks above.

2.3. Workflow Data Dictionary

This table outlines the key information used and produced by this workflow, specifically for Surgical Preauths. This form represents the required items on a surgical preauth.

Field Name	Info	Options (if applicable)	Is required?	Type
consent_token	The consent token for the patient visit		True	string
intervention_code	Unique identifier to the intervention. Must be one that needs_a_preauth.		True	string
surgery_date	The expected surgery date.		True	An ISO 8601 timestamp of the date
chief_complaint	The complaint that caused the patient to seek medical care.		True	string
vital_signs	Patient's vital signs eg. Heart rate, Blood pressure, Respiratory rate, Temperature and Oxygen saturation.		True	string
history_of_present_illness	History of present illness.		True	string
physical_examination	Description of findings from physical examination.		True	string
investigation_report_details	Investigations.		True	string
type_of_anaesthesia	Type of anaesthesia.	General Anaesthesia, Local Anaesthesia, Spinal Anaesthesia, Sedation	True	string
is_condition_related_to_employment	Is the patient's condition related to employment?.		False	boolean
is_condition_related_to_auto_or_other_accident	Is the patient's condition related to auto/other accident?.		False	boolean
is_co_insured	Is the patient co-insured?.		False	boolean
co_insurance_details	Co-insurance Details if the patient is co-insured.		False	string (should be string, boolean from image is likely error)
doctors	Array of Attending Doctors/Clinical Officers consent.		True	array
items	Array of items in the preauth request.		True	array
diagnoses	Array of diagnoses in the preauth request.		True	array
attachments	Array of attachments in the request.		False	array

Some items in the general workflow dictionary have their own specific workflow dictionaries. Below is the list that applies to this particular preauthorization.

2.3.1. Preauth Doctor

This component represents the details of a doctor or clinical officer whose consent is required for a pre-authorization.

Field Name	Info	Options (if applicable)	Is required?	Type
identification_number	The unique ID for the doctor.		True	string
identification_type	The type of ID being used.	registration_number, National ID, Alien ID, Refugee ID	True	string
regulation_body	The licensing body. Defaults to KMPDC.	KMPDC, COC, NCK, PPB	True	string
is_primary	Whether this is the primary doctor for the preauth.		False	boolean

2.3.2. Preauth Items

This component represents the individual billable items or sub-services included within a pre-authorisation request.

Field Name	Info	Options (if applicable)	Is required?	Type
name	The item or service name.		False	string
unit_price	The unit price charged for this item.		True	float (up-to 2dp)
quantity	The quantity of the item.		False	float (up-to 2dp)
charge_date	The charge date for the item. Defaults to today.		False	ISO 8601 timestamp

2.3.3. Preauth Diagnosis

This component represents the diagnostic information associated with a pre-authorization request.

Field Name	Info	Options (if applicable)	Is required?	Type
icd_code	The ICD 11 code.		True	string

2.3.4. Preauth Attachments

This component represents the supporting documents or files that are attached to a pre-authorization request.

Attachments are uploaded as binary multipart parts (not base64); each entry's file_field_name names the binary part it links to. See Adding Attachments for the full mechanics.

Field Name	Info	Options (if applicable)	Is required?	Type
file_field_name	Names the multipart part that carries this file's binary. Can be any name, as long as it matches the part.		True	string
document_title	Title of the document.		True	string
document_type	The document classification.	BIOPSY_RESULT, CASE_NOTES_JUSTIFYING_ADMISSION, CASE_NOTES_INDICATING_NEED_FOR_DEVICE, CASE_SUMMARY, CLINICAL_DOCUMENTATION, CRITICAL_CARE_UNIT_CASE_NOTES, CONSULTANT_REPORT, DIAGNOSTIC_REQUESTS, DIALYSIS_CHART, DISCHARGE_SUMMARY, FINAL_BILL, INTERIM_BILL, HISTOPATHOLOGY_RESULTS, IMAGING_ORDER, IMAGING_RESULT, KMPDC_FORM, LOU, LAB_ORDER, LAB_RESULTS, LAB_TESTS, MEDICAL_REPORT, PRESCRIPTION, PRIOR_BASIC_DIAGNOSTIC_IMAGES, PROFORMA_INVOICE, RADIOLOGICAL_EXAM, RADIOLOGY_REQUEST, REFERRAL_LETTER, RHESUS_FACTOR, SHA_REFERRAL_FOR_OVERSEAS_TREATMENT_FORM, STAGING_RESULTS, TREATMENT_PLAN, THEATRE_LIST, ULTRASOUND, PREAUTH_FORM, OTHER	True	string
file_blob	The binary file part. Uploaded as raw binary multipart (not base64).		True	file