Pre-Authorisation Request Triage for TPAs

• Head of Cashless Operations
• TPA Medical Officer
• TPA Operations Manager
• Provider Network Manager

Network hospitals send cashless requests at all hours: the pre-authorisation form, the treating doctor's notes, investigation reports and a cost estimate, sometimes as a fax turned into a PDF. The medical officer has to work out what is being asked, whether the file is complete and what the policy allows, against a clock that patients, hospitals and IRDAI all watch.

We build a triage layer that sits between hospital requests and your medical officers. It reads each request, identifies whether it is an initial request, an enhancement or a final discharge approval, and extracts the clinical and cost details. It checks the file against a procedure-specific document checklist, looks up the member's policy terms and the hospital's agreed tariff or package, and builds a one-screen summary with every fact linked to its source page. Incomplete files get a drafted query for the desk team. Complete files are ranked by urgency for a medical officer, who makes the decision in your existing TPA system.

• Recognises request type: initial authorisation, enhancement or final discharge approval
• Extracts provisional diagnosis, proposed line of treatment, expected length of stay, room category and estimated cost
• Checks completeness against document checklists configured per procedure or specialty
• Looks up waiting periods, pre-existing disease declarations, sub-limits and room-rent eligibility from the policy record
• Compares the estimate with the hospital's agreed tariff or package rate and highlights differences
• Drafts query letters for missing items and ranks complete requests using urgency rules set by your medical team

1. 01Receive the requestRequests arrive from the hospital portal, a shared inbox or fax-to-email and are matched to the member and the hospital.
2. 02Identify and extractThe request type is identified, and clinical, cost and member fields are extracted with source-page references.
3. 03Check completenessA procedure-specific checklist confirms the required documents; incomplete files go to the desk team with a drafted query.
4. 04Look up policy and tariffPolicy terms and the hospital's agreed tariff or package are pulled and compared with the request.
5. 05Prioritise and summariseComplete requests are ranked by urgency rules and presented as a one-screen summary with flags.
6. 06Medical officer decidesThe medical officer approves, partially approves, queries or declines in the TPA system, and the decision and reasons are logged.

1. Intake
   • Hospital portal connector
   • Shared inbox and fax-to-email reader
   • Member and hospital matching
2. Document understanding
   • OCR with handwriting support
   • Request-type classifier
   • LLM extractor for clinical and cost fields
3. Policy and tariff context
   • Policy terms lookup from the member master
   • Hospital tariff and package master
   • Diagnosis and procedure code suggestions for coder review
4. Triage and review
   • Completeness checklist engine
   • Urgency ranking rules
   • Medical officer summary screen
   • Query letter drafts
5. Integration and audit
   • TPA platform adapter
   • Decision and turnaround log

Medical officers make every approval, partial approval, query and denial, and desk staff review each drafted query before it is sent. The system never contacts the hospital with a decision on its own and never judges medical necessity.

• TPA or insurer cashless platform (via API or database staging)
• Hospital and provider portals
• Shared inboxes and fax-to-email gateway
• Policy administration system or member master
• Hospital tariff and package master
• MIS and data warehouse for turnaround reporting

• No automatic approval or denial at any stage
• Clinical fields shown only when found in the documents, with the source page; absent information is marked absent, not inferred
• Urgency rules written and versioned by the medical team
• Drafted queries reviewed by a person before sending
• Health data masked in logs and kept in your chosen cloud region

• Helps TPAs and insurers work towards IRDAI expectations on time-bound cashless decisions while keeping clinical judgement with qualified medical officers.
• Processes health data only for claim handling, supporting purpose limitation under India's DPDP Act 2023.

• 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.

• Healthcare & Hospitals

  Insurance Pre-Auth and Claim File Preparation for Hospitals

  Assemble cashless pre-auth, enhancement and final claim files for TPAs, insurers and government schemes, and check each against the payer's checklist before submission.

• Insurance

  Claim Status Voice Helpline for Policyholders

  An inbound voice agent that verifies callers, explains live claim status in plain language, sends pending-document lists on WhatsApp and transfers complaints and sensitive cases to people.

• Insurance

  Tampered and Fraudulent Document Detection

  Score claim documents for signs of editing, fabrication and reuse, explain each signal, and route high-risk files to your investigation team instead of labelling anyone a fraudster.