Pre-authorisation is the process by which a network hospital obtains approval from your insurer before charging your policy for a cashless stay. For the patient, it is largely invisible — the hospital manages it. But when it breaks down (delays, partial approvals, enhancement queries, denials), you need to understand how to intervene.
Who Is Involved in Pre-Authorisation
| Party | Role |
|---|---|
| Policyholder / patient | Presents health card and ID at admission; provides consent for insurer to access medical details |
| Hospital’s insurance desk | Submits the pre-auth request form with diagnosis, treatment plan, expected cost, and patient’s policy details |
| TPA (Third Party Administrator) | Receives the pre-auth from hospital; verifies policy coverage, waiting periods, limits; issues approval or queries |
| Insurer | Ultimately responsible; TPA acts on insurer’s authority as per tariff agreement |
Planned Hospitalisation: Pre-Auth Process
For surgeries, procedures, and scheduled admissions:
Step 1: Confirm Network Hospital
Verify the hospital is in your insurer’s cashless network — the insurer’s website lists empanelled hospitals by city or pin code. Call the hospital’s insurance desk before booking to confirm the insurer is active (networks are periodically updated).
Step 2: Hospital Submits Pre-Auth Request (3–5 days before admission)
The hospital insurance desk sends to the TPA:
- Patient’s insurance details (policy number, health card)
- Confirmation of identity (Aadhaar or equivalent)
- Treating doctor’s details and proposed admission date
- Provisional diagnosis and ICD-10 code
- Proposed procedure / surgery (CPT code where applicable)
- Estimated cost breakdown (room, surgery, anaesthesia, consumables, medicines)
Step 3: TPA Reviews Eligibility
The TPA checks:
- Policy is active and in force
- Insured is within the coverage period
- Waiting periods for the diagnosed condition have elapsed
- Sum insured available (remaining after any prior claims)
- Any applicable sub-limits or room rent caps
- Pre-existing disease status of the condition
Step 4: Approval Letter Issued
The TPA issues a pre-auth approval letter to the hospital specifying:
- Approved amount
- Approved room category (tied to room rent limit in policy)
- Approved procedure / diagnosis
- Validity period of the approval
If the room category implied by the approved room rent is lower than desired, you can negotiate with the hospital — but any excess room cost will be borne by you.
Emergency Hospitalisation: Pre-Auth Process
For emergency admissions (accident, acute medical event), the sequence is reversed:
- Admission first — patient is admitted based on medical need
- Notification within 24 hours — the hospital must notify the TPA within 24 hours of admission
- TPA issues emergency pre-auth — based on available information; may be provisional
- Documentation follows — full documentation submitted by hospital within 48–72 hours
- Final approval issued; differential costs during undocumented window may be reviewed
IRDAI 2024 circular on timelines:
- Emergency pre-auth: TPA must respond within 1 hour of notification
- If the TPA fails to respond within 1 hour, the hospital can proceed with treatment and the insurer cannot reject on pre-auth delay grounds
Partial Pre-Authorisation: What It Means
A partial approval occurs when the TPA approves less than the expected cost. This is common and does not mean the rest will be rejected.
Typical reasons for partial approval:
- Room rent limit lower than the requested room category
- Sub-limits on specific procedures (e.g., cataract cap, knee replacement cap)
- Only the base procedure approved; optional procedures pending separate auth
- Consumables excluded (IRDAI non-payable list)
What to do with a partial approval:
- Ask the hospital’s insurance desk for a breakdown of what was approved vs excluded
- Decide whether to proceed at the approved room category (lower room cost) or upgrade and self-fund the difference
- For large gaps, call the insurer’s helpline directly — some approvals can be enhanced if additional clinical information is provided
Enhancement Queries: During the Hospitalisation
If your condition requires more treatment than initially anticipated, the hospital must seek a coverage enhancement from the TPA.
Common triggers for enhancement queries:
- Total bill exceeding originally approved amount by a material margin
- New diagnosis identified during the stay (e.g., post-surgical complication)
- ICU admission not in the original approval
- Extended hospital stay beyond the approved duration
- Additional surgery or procedure
The enhancement process:
- Hospital insurance desk sends an enhancement request with updated clinical notes
- TPA reviews and responds (same 1-hour IRDAI deadline applies)
- Enhancement is approved, partially approved, or denied
If enhancement is denied, the excess amount above the original approval is your responsibility. The insurer will typically settle the original approved amount; you pay the rest.
Pre-Auth Denial: Your Options
If the TPA denies the pre-authorisation request:
| Action | Details |
|---|---|
| Understand the specific reason | Insurer must cite the policy clause in writing |
| Call the insurer’s claims helpline | Some denials are reversed with additional clinical information |
| Request emergency escalation | Ask the TPA for escalation to senior reviewer if clinically urgent |
| Pay and file reimbursement | A reimbursement claim is a separate decision — denial of pre-auth is not a final claim rejection |
| File grievance after discharge | If the reimbursement is also rejected, follow the four-stage escalation process |
Note: The most common pre-auth denial reasons — PED waiting period violations, non-network hospital errors, or missing policy details — can often be addressed on the same day if caught early.
Documents the Hospital Insurance Desk Needs From You
Bring these to every planned admission:
- Original health insurance card (physical or digital via insurer app)
- Government-issued photo ID (Aadhaar, PAN, passport)
- Copy of the health insurance policy (first page)
- Doctor’s referral / appointment letter (for planned procedures)
- Pre-test reports referenced in the treatment plan
For a complete comparison of cashless and reimbursement mechanics, see Cashless vs Reimbursement Health Insurance.