Pre-authorisation, networks and direct billing

Most refused claims are not clinical disputes.

They fail because a procedural step was missed — usually one that takes a phone call.

What pre-authorisation is

• The insurer agreeing in advance to cover a specific treatment.
• Usually required for planned admissions and procedures.
• Often required for expensive diagnostics.
• Sometimes required for outpatient specialist care.
• Check which categories require it in your policy.

Why it exists

• It confirms the treatment falls within the policy.
• It confirms the provider and price are acceptable.
• It allows the insurer to arrange direct payment.
• It gives you certainty before committing.
• Used properly it protects you as much as the insurer.

How to obtain it

• Contact the insurer as soon as treatment is proposed.
• Provide the diagnosis and proposed procedure.
• Provide the hospital and clinician details.
• Provide the estimated cost.
• Ask your doctor for a supporting letter.
• Ask how long a decision takes.
• Get the approval in writing with a reference number.

What the approval should state

• Which treatment is approved.
• At which facility.
• For which dates.
• Up to what amount.
• What remains your responsibility.
• Keep it with your travel documents.

Emergencies

• Treatment comes first; authorisation follows.
• Most policies require notification within a set period.
• Save the emergency number in your phone now.
• Ask a companion to call if you cannot.
• Ask the hospital to contact the insurer directly.
• Record who called, when, and the reference given.

Provider networks

• Insurers negotiate rates with specific providers.
• In-network usually means direct billing and full cover.
• Out-of-network often means reduced or no payment.
• Networks change; verify at the time of treatment.
• Ask the insurer to confirm the specific hospital in writing.
• Ask whether the individual clinician is also in network.

The clinician trap

• A hospital can be in network while a clinician within it is not.
• This produces unexpected separate bills.
• Ask about the surgeon, anaesthetist and radiologist specifically.
• Ask who else may bill you separately.
• Raise it before admission, not after.

Ask how long approval takes

• Some approvals take days rather than hours.
• Ask whether urgent cases are expedited.
• Ask what to do if the date approaches without a decision.
• Build the delay into your scheduling.
• Do not book non-refundable travel before approval.

Direct billing

• The insurer pays the hospital instead of you.
• Requires a guarantee of payment to be issued.
• Ask the insurer to send it to the hospital in advance.
• Confirm with the hospital that they have received it.
• Take a copy with you regardless.
• Do not assume it has arrived because it was promised.

Confirm again close to the date

• Networks and approvals can change between booking and admission.
• Reconfirm a few days beforehand.
• Reconfirm the guarantee of payment is still valid.
• Note the reference of that reconfirmation too.

When direct billing is not available

• You pay and claim reimbursement afterwards.
• Ensure you can actually fund the amount.
• Ask about typical reimbursement timescales.
• Keep original itemised invoices.
• Keep proof of payment separately.

Keep the assistance number reachable

• Store it in your phone and on paper.
• Give it to whoever travels with you.
• Note the policy number alongside it.
• Check whether the line operates around the clock.
• Check which languages it supports.

If authorisation is refused

• Ask which clause the decision rests on.
• Ask what additional information would help.
• Ask your doctor to write a fuller justification.
• Ask whether an alternative treatment would be approved.
• Use the formal appeal route.
• Do not delay urgent care while appealing.

Ask for an estimate of your own share

• Deductible, co-insurance and any excluded items.
• Ask for the figure in writing before admission.
• Ask what could make it higher.
• Arrange the funds in advance.

If the plan changes during treatment

• Approvals are usually specific to what was requested.
• Tell the insurer promptly if the plan changes.
• Ask the hospital to submit an updated request.
• Confirm the extension in writing.
• Unapproved additions are a common source of unpaid bills.

Pharmacy and outpatient claims

• Small claims still require the same evidence.
• Keep prescriptions matching each receipt.
• Check whether outpatient care has its own deductible.
• Check whether referral is required for specialists.
• Submit in batches to reduce administration.

Second opinions and the insurer

• Some policies fund a second opinion.
• Some require one before approving major surgery.
• Ask whether they choose the reviewing clinician.
• Ask whether their opinion is binding on the claim.
• Ask how long the process takes.
• Build that time into your planning.

Keep a single file

• Policy wording and schedule.
• All authorisations with reference numbers.
• Guarantees of payment.
• Invoices and receipts.
• A log of calls with names and dates.
• This file settles most disputes quickly.

Keeping the hospital informed

• Give admissions your policy number on arrival.
• Give them the authorisation reference.
• Ask them to confirm they can bill the insurer.
• Ask what they will charge you directly.
• Sort this before the procedure, not at discharge.

Before any planned admission

• Authorisation obtained and in writing.
• Hospital confirmed in network.
• Clinicians confirmed in network.
• Guarantee of payment received by the hospital.
• Your own share of costs understood.
• Emergency contact numbers saved.

The point to remember

Three things:

1. Get authorisation in writing with a reference number.
2. Confirm the clinicians are in network, not just the hospital.
3. Verify the hospital actually received the guarantee of payment.

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