Glossary & Guidelines: Hospital Patient Administration

Responsible Roles

	Confirm the Authorisation by phoning the medical aid before the patient are admitted in the hospital. When a patient is admitted in the hospital from the emergency department, the receptionist must arrange with the medical aid for the authorisation. The information must be completed on the system. Assist the patient in getting the authorisation with the correct information from the medical aid. For a private patient, a quotation must be signed and will be used as the authorisation before the patient are admitted in the hospital.
	Assist the patient and receptionist if they struggle in getting the authorisation or confirmation. All communication with medical aids must include the authorisation number. Apply for a new Authorisation number or extension on the authorisation when the patient condition has changed. Ensure private patients sign a quotation for the procedure that will be done.
	Ensure the correct training was provided to the receptionist to assist patients in getting the authorisation. Assist the patient and receptionist if they struggle in getting the authorisation or confirmation. Assist the Case Manager when they struggle with the authorisations and updates to the medical aid.

Purpose of Authorisation & Confirmation

The authorisation is the most important part before a patient are admitted into the hospital. This will assist in less debt management and assist in receiving the money for the procedure that must be done on the patient.  Co-payments can be discussed with the patient before the patient are admitted in the hospital. Will assist in checking when an amendment must be received from the medical aid according to the authorisation that was given. Confirmation must be done to ensure the correct details were given to the medical aid and the authorisation are correct.

Critical Steps of  Authorisation & Confirmation

The Hospital must obtain or confirm the authorisation from the patient’s medical aid for admission into the Hospital and for a specific procedure to be done. 

The difference between Authorisation and Confirmation:

Authorisation:  This is the initial process whereby the patient obtains an authorisation number from his/her medical aid to get approval for a procedure to be done in a hospital.  The patient or the medical practice needs to supply this authorisation number to the admission staff during the Pre-Admission stage.

Confirmation:  This is the process whereby the hospital contacts the medical aid and gets confirmation that the authorisation number supplied to them by the patient or medical practice is 100% correct and valid.

Arrange / Confirm Authorisation

Patients will under normal circumstances obtain the authorisation directly from their medical aid and will complete the detail on the Pre-Admission Forms. It is important to ensure that each patient on the theatre list completes a pre-admission form.

• Ensure that valid authorisation has been received from medical aids for all patients with medical aid benefits.
• Ensure that the procedure authorised corresponds with the intended procedure.
• Ensure that the authorisation number appears on the patient file (copy of Authorisation from M/A in patients’ file at admissions).
• A motivation for additional procedures needs to be approved by the medical aid.
• Best practice will be to not allow a medical aid patient to be operated on without the valid authorisation number.  The patient can be admitted, but may not be pushed to the theatre unless the authorisation number is confirmed.
• All authorisation numbers need to be confirmed by the hospital staff with medical aids.

The following information is important to confirm: 

Confirm CPT (Current Procedural Terminology) Codes

• A CPT4 Code is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians and medical aids. The 4 stands for 4th edition of the code set.
• Phone the Medical Aid to confirm that the CPT Codes authorised by the medical aid correspond with the procedure booked as per the theatre booking list. 
• Confirm that the authorisation number supplied by the patient is correct.

Determine Co-Payment with Medical Aid and Deposit with Private Patients

• Phone the Medical Aid to find out if there is a co-payment associated with the procedure.
• Private patients will need to pay the full procedure amount before admission or pay a deposit for the procedure that must be performed depending on the arrangement with the patient.
• Inform the patient telephonically or via SMS about the amount of the co-payment or deposit and that it is payable before admission. It is important that the patient is aware of the fact that the co-payment or deposit is payable before the procedure can take place.

Import and Validate Patient on GoodX

• The hospital can validate the patient information electronically with most medical aids to confirm if the demographic data of the Main member and Patient is correct and if they are still active on the medical aid.
• The data import can also be used to import the demographic details of the patients or all the dependants. The medical aid name and the medical aid number is the only information you will need to do the import from most medical aids. The information you will receive from the medical aids will depend on the different medical aids.

Make sure that all the relevant information on the Pre-Admission is correct:

1. Patient, Main Member, and Guarantor full names
2. ID Numbers or Passport numbers
3. Medical Aid number
4. Type of Procedure
5. Date of Procedure
6. Attending doctor
7. CPT4 Code for the procedure
8. ICD10 codes
9. Any co-payments needed (notes on GoodX)