Pre-Authorisation

  1. The Trust shall receive all the pre-authorisation requests from NWHs, scrutinize them as per guidelines issued by the Trust with the help of medical professionals and accord final approval within 12 hours of submission of request by NWH.
  2. A query on an incomplete pre-authorisation request can be raised not more than once by the panel doctor. In case of a query by panel doctor, an additional time of 6 hours will be allowed to the Trust so as to enable to offer final approval within 18 hours.
  3. Wherever required the services of necessary specialists shall be utilized by the Trust to evaluate special cases.
  4. The responsibility & liability of management of a case solely rests with the treating doctor and the NWH. The pre-authorisation remarks of panel doctor or Trust shall be construed as advisory in nature and shall not in any way alter the line of treatment proposed by the treating doctor.
  5. No recommendation for reduction in package price shall be made at pre-authorisation stage by the Trust.
  6. Telephonic approval: The NWH shall obtain Telephonic pre-authorisation through dedicated telephone lines in all cases of emergencies. NWH shall only obtain a telephonic approval after confirming that the particular case falls within the purview of the scheme. A telephonic pre-authorisation shall be deemed to be a provisional approval, and shall necessarily be followed by a regular pre-authorisation within 24 hours.
  7. The rejection of pre-authorisation by Trust shall not be construed as refusal of treatment to the patient by the Trust. The rejection of pre-authorisation merely means the disease of the patient and treatment choices are out of the listed therapies.
  8. The approval of pre-authorisation by the Trust shall be based on online evidence of diagnosis and choice of treatment arrived at by the treating doctor. The approval by Trust shall be deemed as an approval of the case for financial assistance under the scheme and shall not be construed as an endorsement of treatment by the NWH.
  9. Enhancement (Package price adjustment): The NWH shall provide end to end cashless services within the package. However NWH may apply for enhancement of the package price in case of exigencies prior to discharge as per Trust guidelines.

24-hr e-Preauthorisation

  1. All pre-authorisations shall be handled by the Trust through existing online e-preauthorisation workflow. Trust shall establish necessary IT infrastructure to handle additional load of pre-authorisations on account of scheme.
  2. The pre-authorization shall be done 24x7x365 days.

Scheme Technical Committee

A technical committee for the scheme, herein after called The scheme technical committee shall exercise the following powers of recommendation to the CEO:

  1. Final decision on pre-authorizations in case of difference of opinion.
  2. Authorization of utilization of buffer amount;
  3. Authorization of Package Price enhancements or Pricing for unlisted therapies to be paid from the buffer;
  4. Modification of nomenclature and relocation of any listed therapy;
  5. Minor changes in protocols for the listed therapies;
  6. Framing of guidelines and evolving objective criteria to assist proper selection of cases in order to reduce moral hazard.

Composition of Scheme Technical Committee

The scheme technical committee shall consist of the following members:

  1. Executive Officer (Technical);
  2. Joint Executive Officer (Technical) and
  3. Medical Doctor nominated by the Government.