At 5:10 pm, the surgeon says the patient can leave. The hospital cannot close the cashless bill yet. A new consumable appeared, the operative note is not in the packet, and the insurer has asked why the final amount exceeds the pre-authorised estimate.
The patient experiences one delay. The desk sees four unfinished handoffs.
This playbook is for private health-insurance cashless work at an Indian network hospital. It does not describe PM-JAY package claims, which run on a separate scheme process.
Takeaways:
- The one-hour pre-authorisation and three-hour final-authorisation clocks belong to the insurer after receipt of the relevant request.
- A complete packet and a visible query log matter more than repeated phone calls.
- Clinical, estimate, policy, and final-bill changes need one amendment trail.
- A note-drafting tool can sit upstream; it does not file or decide the claim.
Run the case as two linked packets
The first packet asks whether the insurer will authorise cashless treatment under the policy. The second asks for final authorisation against what actually happened and what the hospital billed.
Treat them as linked versions of one case.
| Stage | Hospital desk needs | Clinical owner contributes | Insurer or TPA returns |
|---|---|---|---|
| Pre-authorisation | Member and policy details, network status, form, estimate, supporting records | Diagnosis, indication, treatment plan, relevant history and investigations | Approval, partial approval, query, or denial under the policy |
| Amendment | Prior reference, changed facts, revised estimate, reason for change | Updated diagnosis, procedure, plan, or complication record where applicable | Revised decision or further query |
| Final authorisation | Final bill, discharge request, completed records, prior decisions and amendments | Procedure or treatment record and discharge summary | Final authorised amount, deductions, query, or denial |
The exact documents vary by payer, policy, and case. HDFC ERGO’s published cashless process, for example, asks for a completed pre-authorisation form, prescription with diagnosis and planned treatment, supporting investigations, expected-cost estimate, and relevant history. It names extra records for certain conditions and accidental cases (HDFC ERGO cashless process). Use the current checklist for the payer handling the case.
The regulatory clock starts at receipt
IRDAI’s health-insurance FAQ says the insurer should decide a cashless authorisation request immediately and no later than one hour after receiving it. The same FAQ says final authorisation should be granted within three hours after the insurer receives the hospital’s discharge authorisation request (IRDAI health department FAQ). The underlying Master Circular on Health Insurance Business is dated 29 May 2024.
Those limits are easy to quote badly. They are insurer turnaround requirements from receipt. They do not mean:
- the hospital may wait an hour before sending a complete packet;
- every query is automatically resolved inside the original clock;
- a planned admission needs no advance local preparation;
- every bill item is covered; or
- every patient physically leaves within three hours.
Capture two timestamps: when the desk sent the complete request and when the payer acknowledged receipt. If a query arrives, log the exact question, owner, response, attachments, and new receipt evidence. “Followed up” is not a useful case state.
Build a pre-authorisation packet that can be read cold
The reviewer was not present when the patient arrived. The packet has to explain the case without a ward-side conversation.
Use a cover sheet with:
- patient and member identity, checked against the payer record;
- policy or card details and network confirmation;
- planned or emergency admission status;
- treating clinician and hospital contact;
- diagnosis and clinical indication in the treating record;
- proposed treatment or procedure;
- investigations that support the request;
- expected dates and cost estimate;
- attached-document list; and
- one hospital case owner.
Do not add clinical facts at the desk because a field is blank. Return the gap to the treating team. A fast invented answer is worse than a visible query.
The desk should also distinguish three amounts: the hospital estimate, the insurer’s approved amount, and the patient’s possible non-payable or policy share. They are not interchangeable, and a pre-authorised amount is not the final settlement.
Make every query a work item
Payer queries tend to arrive as short text against a much larger case. Convert each one into a row.
| Received | Query | Owner | Due | Response evidence | State |
|---|---|---|---|---|---|
| 11:04 | Investigation supporting stated diagnosis not attached | Ward coordinator | 11:20 | Named report, date, page, upload receipt | Sent 11:16 |
| 14:32 | Revised procedure differs from initial request | Treating team | 14:50 | Clinical update, revised estimate, amendment reference | Awaiting receipt |
Use states staff can act on: new, assigned, waiting on clinical team, waiting on patient, sent, receipt confirmed, payer review, decided. Avoid “in process.” It conceals ownership.
Keep the original request and every amendment. Do not overwrite the first estimate or diagnosis in a shared spreadsheet. The sequence explains why the case changed.
Amend before the final bill becomes a surprise
Treatment can change after pre-authorisation. A planned procedure may expand, an implant may change, complications may add care, or the length of stay may move. The desk needs a trigger list for when to seek an amendment under the payer’s process.
For every change, record:
- what changed;
- when the hospital knew;
- who made the clinical decision;
- the supporting record;
- the estimate effect;
- when the payer received the amendment; and
- the returned decision or query.
The hospital should not expect the discharge desk to reconcile an unexplained difference between the pre-authorised plan and the final bill in a few minutes. Make the case current while care is happening.
Prepare discharge before the discharge order
The three-hour insurer clock does not excuse a packet assembled at the end. Start the final checklist when discharge becomes likely.
Reconcile the pre-authorisation, amendments, treatment record, final diagnosis, procedure or intervention, investigation results, discharge summary, and itemised bill. Check that dates, clinician names, and amounts agree. If they do not, route the discrepancy to the owner. Do not quietly edit a clinical document to fit a billing line.
Then send the final authorisation request through the applicable payer or TPA channel and preserve receipt evidence. Keep the patient informed using timestamps the desk actually has. A promise based on “usually” is not a status update.
Protect the packet as health data
The packet contains identity, policy, financial, and health information. The Digital Personal Data Protection Act, 2023 requires consent to be free, specific, informed, unconditional, and unambiguous for processing based on consent, and it places duties around purpose and handling on data fiduciaries (DPDP Act, 2023). Other lawful uses and insurance obligations may also apply to a particular case; the hospital should follow its approved legal and privacy process.
Operationally, keep the case inside approved channels. Restrict access by role. Do not send full packets into informal groups because the insurer asked for one missing page. Record what was shared, with whom, for which case, and under which approved process. Apply the hospital’s retention and deletion policy to local working copies.
Keep PM-JAY and private cashless separate
The desk may handle private insurance, TPAs, PM-JAY, employer schemes, and state schemes during one shift. Shared staff does not mean shared rules.
This article covers a private health-insurance cashless request governed by the applicable policy, insurer or TPA process, and IRDAI framework. PM-JAY uses its own package, pre-authorisation, transaction, and audit machinery. Read the separate PM-JAY claim documentation guide for that path.
The same separation applies to NHCX. The NHCX explainer covers the exchange. Do not label an ordinary portal upload as NHCX connectivity, and do not infer that a hospital product sends claims merely because it contains a claims module.
Patient Square sits upstream of the desk
Patient Square is an AI clinical platform. Practice Copilot brings the whole practice under one AI copilot: an ambient AI Medical Scribe that hands back a structured SOAP note, ICD-10 suggestions, and a prescription draft minutes after the visit, plus a bundled AI EHR, scheduling, and messaging as you move up the plan. Hospitals get Hospital Copilot.
For this workflow, the boundary matters more than the module list. Patient Square does not claim insurer or TPA connectivity, cashless pre-authorisation submission, NHCX connectivity, automatic claim filing, or live ABDM integration. ABDM integration is on the roadmap. ICD-10 output is a suggestion for authorized review, not a coding decision. Prescription content is a draft, not transmission to a pharmacy.
A reviewed clinical note may provide cleaner upstream source material for the hospital team that assembles the packet. It does not guarantee approval or replace the payer checklist, policy, treating clinician, coder, billing team, or insurer decision.
Bring one de-identified query trail to a process review. compare the options, then keep submission and decision authority exactly where the hospital and payer rules put them.