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Pre-Approval / Pre-Authorisation Hospitalisation: What You Need to Know

Pre-Approval / Pre-Authorisation Hospitalisation: What You Need to Know

Last Updated on by Tree of Wealth

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Obtaining pre-authorization is usually required for policyholders planning to undergo hospitalization for medical treatment or procedures. The specific pre-authorization requirements vary depending on the policyholder’s insurance company and plan.

By obtaining pre-approval, policyholders can confirm coverage for medical treatment before proceeding. They can request this from a medical specialist within their insurer’s panel of accredited clinics.

While patients typically submit their insurance claims after undergoing medical treatment, pre-approval guarantees coverage before treatment, removing any uncertainty.

Pre-approval involves obtaining approval for medical expenses before undergoing surgery or admission to private specialist clinics or hospitals associated with the insurance company. To secure pre-approval from their insurer, patients or doctors must first inform the insurance company and seek approval before receiving any form of care or treatment.

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While criteria for pre-approvals may differ among health insurance companies, the more costly the service or treatment, the more likely it is that pre-approval is required. Policyholders are advised to contact their health insurance company before undergoing any treatment or service to ensure pre-approval requirements are met.

In-network healthcare providers may handle the pre-approval process for their patients, but if a policyholder wishes to receive care from a clinic or hospital outside their plan’s network, they must handle the pre-approval process themselves.

Regardless of who handles the pre-approval process, policyholders are recommended to confirm with the insurance company that all necessary steps have been taken. If pre-approval has not been obtained, the policyholder and patient will still be responsible for the financial burden.

Why is Pre-Approval Required?

There are various reasons why a health insurance provider may require a pre-approval. Some of these include:

  1. Ensuring that the medical service or drug prescription is medically necessary for the policyholder. For example, a drug used for cosmetic purposes may require pre-approval to verify that it is being used to treat a medical condition, and not for cosmetic purposes.
  2. Confirming that the new medical treatment or drug prescription will not negatively interfere with the policyholder’s pre-existing medical treatment or prescribed medication.
  3. Ensuring that the medical treatment or prescription medicine prescribed is the most cost-effective option for treating the patient’s condition. For example, if there are two drugs available to treat a condition, and one is more expensive than the other, the insurer may seek clarification from the doctor as to why the more expensive option is necessary.
  4. Avoiding redundancy in medical treatment. This can occur when multiple specialists are involved in a patient’s care. The insurer may require that the second specialist review the results of any previous tests or treatments before approving additional tests or treatments.
  5. Verifying that an ongoing medical service is still necessary and beneficial for the policyholder’s wellbeing. Additional sessions may be pre-approved if progress is being made, but may be denied if the treatment is not effective or harmful.

Regardless of whether the pre-approval process is initiated by the patient or the healthcare facility, it is recommended that policyholders double-check with their insurance company to ensure that all necessary steps have been taken to obtain pre-approval. Failure to comply with pre-approval requirements may result in the policyholder being responsible for all associated costs.

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Who is eligible for pre-approvals?

It is highly advisable for policyholders with integrated shield plans to apply for pre-approval with their respective insurers, as a vast network of medical specialists is available for this purpose. Otherwise, the medical expenses incurred for hospitalization, surgery, or treatment received from these specialized centers may not be fully reimbursed.

When is Pre-Authorisation Needed?

In general, pre-authorization is necessary for any medical treatment or procedure that is considered to be “elective” or non-urgent, such as cosmetic surgery or certain diagnostic tests. In addition, pre-authorization is often required for treatments or procedures that are considered to be experimental or investigational, as well as for treatments or procedures that are not covered under the policyholder’s insurance plan. It is always best to check with the insurance company to determine whether pre-authorization is required for a specific medical treatment or procedure.

Below are a few reasons when Pre-Authorisation is needed:

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Protecting your interests

By conducting a review and assessment of proposed treatment or medication costs against modern medical standards, health insurance companies can ensure that policyholders are being charged reasonable rates.

Affordable medical expenses

Pre-approvals enable insurers to help policyholders manage rising medical costs due to inflation, allowing for premium rate adjustments in line with the current economy.

Reduced cash outlay

Policyholders can rely on their insurer to handle deposit and other necessary charges required by clinics or medical specialists prior to treatment.

Avoiding bill shock

Pre-approvals inform policyholders of the amount their insurance provider can cover before treatment, preventing unexpected out-of-pocket expenses.

Hassle-free, cashless claims

Covered by the approved amount, cashless admissions and paperless claims make payment to clinics or medical specialists stress-free. Facilities can also submit claims on behalf of the policyholder to Aviva.

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Assurance of claims

Pre-approvals provide policyholders with the assurance of their insurance claim outcome, allowing them to focus on full recovery. Seeking pre-approval is highly recommended for non-emergency specialist appointments under Aviva’s panel specialist.

Increased coverage and benefits

Pre-approval from health insurance providers can also lead to increased benefits for policyholders, such as higher annual claim limits and extended coverage for pre- and post-hospitalization treatment benefits.

How Do Pre-approvals Work?

In order to proceed with a planned admission or treatment, the policyholder must ensure that their panel specialist submits the Pre-authorisation Request Form, also known as a pre-approval request form, prior to treatment. Another option is for the policyholder to handle the submission themselves by calling their insurer and providing the required information.

Typically, the process of requesting pre-approval takes between 3 to 5 working days. Once pre-approval has been granted, the policyholder can proceed with their treatment or admission, and the insurer will cover the approved expenses as per the policy terms and conditions.

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Provide the following information

  • NRIC & name of the Life Assured
  • Name of the doctor
  • Name of the doctor’s clinic
  • Date of the planned admission/day surgery
  • Name of the hospital/clinic for the admission/day surgery
  • Policyholder’s email address
  • Policyholder’s mobile number

Policyholders must make sure that they meet the following criteria

  • The inpatient treatment or day surgery is done at a private hospital or a private clinic in Singapore;
  • The principal doctor must be one of insurer’s panel specialists;
  • Policyholders are required to make the request at least 5 working days before the admission date; and
  • The admission date should be within 6 weeks from the request date.

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A Quick Guide

Schedule an appointment with a General Practitioner (GP)

To begin the medical consultation process, policyholders should visit a General Practitioner (GP) of their choice. If the GP feels that further treatment from a Specialist is necessary, the policyholder can request a referral to a Specialist within their insurer’s panel to receive consultation at a discounted rate. In the event that hospitalization or day surgery is required, policyholders may contact their insurer’s hotline or advisor, to initiate a request for a Letter of Guarantee (LOG). Approval for the LOG will be subject to the insurer’s assessment and approval.

Arrange an appointment with a Specialist within the insurer’s panel and request a Letter of Guarantee (LOG).

The policyholder should schedule an appointment with a Specialist within their insurer’s panel and provide their insurance e-card for identification purposes to receive consultation at a discounted rate. To request a Letter of Guarantee (LOG) for hospitalization or day surgery, policyholders can contact their insurer’s hotline, which operates 24/7. For elective surgery or hospitalization, the insurer should be given at least three days’ advance notice to assess the policyholder’s request for a LOG. Approval for the LOG will be subject to the insurer’s assessment and approval.

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Have a smooth and hassle-free discharge process. 

The pre-authorized Letter of Guarantee (LOG) will be issued usually within three to five working days to cover the policyholder’s medical expenses, ensuring a hassle-free discharge from the hospital.

Having comprehensive hospital coverage is essential in protecting yourself and your loved ones from unexpected medical expenses. By having adequate hospitalisation coverage, you can have peace of mind knowing that you have access to quality healthcare and financial protection in times of need.

If you have any questions or would like to learn more about our hospital coverage options, please don’t hesitate to contact us.

Our team of experts is always ready to assist you in finding the best insurance plan that meets your needs and budget. Contact us today for reliable hospital coverage.

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