Insurance Pre-Auth and Claim File Preparation for Hospitals

• Head of TPA and Insurance Desk
• Revenue Cycle Manager
• Chief Financial Officer
• Medical Superintendent

A hospital insurance desk handles cashless requests for many insurers, TPAs and government schemes, each with its own forms, portals and document checklists. A pre-auth needs the request form, doctor's notes, investigation reports, a cost estimate and policy and ID documents; the final claim adds the bill breakup, discharge summary, pharmacy bills and implant invoices. One missing report or a mismatch between estimate and notes brings a query, and the patient waits at discharge.

We build a claim file assistant for the hospital insurance desk. When a cashless request starts, it gathers the patient's policy or e-card, ID, doctor's notes, investigations and estimate from the HIS, fills the payer's pre-auth form fields and checks the file against that payer's checklist. For enhancements and final claims, it compares the bill breakup with the discharge summary, OT notes and approved amount, highlights likely non-payable items and missing documents, and drafts replies to TPA queries using the relevant pages of the record. Desk staff review and submit through the payer portal, or through NHCX where the hospital is onboarded. Every file keeps a log of what was sent and when.

• Payer-specific document checklists for insurers, TPAs, PM-JAY, CGHS, ECHS and state schemes, maintained by your desk
• Pre-fills pre-auth and enhancement form fields from HIS data and clinical notes
• Cross-checks diagnosis, procedure, package and dates across notes, estimate and final bill
• Highlights likely non-payable items and room-category issues before submission
• Drafts replies to TPA queries with the relevant pages of the patient record attached
• Tracks each file's submission, query and approval history

1. 01Open the caseWhen a cashless admission is registered, the assistant opens a case and pulls policy, ID and clinical documents from the HIS.
2. 02Prepare the pre-authForm fields are pre-filled and the file is checked against the payer checklist, with gaps listed for the desk.
3. 03Desk review and submissionDesk staff close the gaps, review the file and submit it through the payer portal or NHCX.
4. 04Queries and enhancementsPayer queries are read, the right documents found and a reply drafted; enhancements are prepared when the treating team revises the plan.
5. 05Prepare the final claimAt discharge, the bill breakup is checked against the discharge summary, OT notes and approvals, and missing documents are flagged.
6. 06Submit and trackThe final file is submitted after desk review and its status is tracked through to settlement.

1. Data sources
   • HIS patient, billing and clinical modules
   • Scanned policy cards and ID with masked Aadhaar
   • Payer query emails and portal downloads
2. Document understanding
   • OCR and document classifier
   • LLM extractor for clinical and billing fields
3. Payer rules
   • Checklist library per insurer, TPA and scheme
   • Cross-document consistency checks
   • Non-payable item and room-category rules
4. Desk workspace
   • Case dashboard with gaps and deadlines
   • Query reply drafter
   • Submission tracker
5. Integration and audit
   • Payer portal upload packs and NHCX connector where available
   • Audit log of every submission

Insurance desk staff review and submit every file, and treating doctors confirm any clinical statement in a query reply. The assistant never submits to a payer or changes clinical content on its own.

• Hospital information system (billing, clinical and pharmacy modules)
• Insurer and TPA portals
• National Health Claims Exchange (NHCX) where the hospital is onboarded
• PM-JAY and state scheme portals, through desk-uploaded packs
• Email inbox used by the insurance desk

• No claim, query reply or enhancement submitted without desk review
• Clinical statements drafted only from signed notes and confirmed by the doctor before sending
• Masked Aadhaar only; full numbers never stored, per UIDAI rules
• Payer checklists versioned so every change is traceable
• Access limited to insurance desk roles, with full audit logging

• Helps hospitals meet payer documentation requirements and IRDAI's expectations on faster cashless processing; claim decisions remain with insurers and TPAs.
• Patient health data processed only for claim purposes, in line with the DPDP Act 2023.

• Healthcare & Hospitals

  Discharge Summary and Medical Record Structuring

  Draft discharge summaries from the inpatient file and turn past records into structured diagnoses, procedures, medicines and allergies, each linked to its source for the doctor to verify.

• Healthcare & Hospitals

  Lab Report Digitisation and Trend Extraction

  Turn external lab reports, PDFs and phone photos into structured results mapped to standard test codes, and show trends over time to the treating doctor with every value linked to its source.

• Insurance

  Pre-Authorisation Request Triage for TPAs

  Read incoming cashless requests, check completeness, policy terms and tariffs, and put a prioritised, source-linked summary in front of the TPA medical officer.

• Insurance

  Health Claim Document Extraction

  Turn hospital bills, discharge summaries and investigation reports into structured, checked claim data, with uncertain fields routed to an assessor instead of guessed.