How to fill a pre-auth form for cashless hospitalisation

A pre-auth form has two halves. The patient or attendant fills the policy and personal details and signs the declaration; the treating doctor fills the clinical part — complaints with their duration, provisional diagnosis with ICD-10 code, the proposed line of treatment, admission details and a cost estimate broken down by head — and signs with registration number and hospital seal. Send it with the health card, ID proof, doctor’s notes and reports to the insurer or the TPA named on the card. Most queries come from three gaps: no duration of illness, no ICD-10 code, and a cost estimate given as one figure.

Step by step

1. Use the right form

   Check the patient’s health card. If a TPA is named, use that TPA’s form and portal; if not, the insurance company’s. Most insurers and TPAs also accept the IRDAI standard cashless request form. Download the current one from the Medilock pre-auth directory.

2. Patient’s part

   Patient name, gender, age and date of birth, contact number and address; policy number, member or card ID, and employee ID for a group policy; whether the patient has any other health insurance and its details; previous hospitalisation; family physician, if any. The patient or attendant signs.

3. Treating doctor: the illness

   Nature of illness and presenting complaints, relevant clinical findings, duration of the present ailment and date of first consultation, provisional diagnosis with its ICD-10 code, and past history of the present illness.

4. Treating doctor: the treatment

   Proposed line of treatment — medical management, surgical, intensive care, investigation or non-allopathic. For surgery, the name of the procedure and its ICD-10 PCS code. For an accident: how it happened, date of injury, whether it was a road accident, whether police were informed and the FIR or MLC number, and whether alcohol or drugs were involved. For maternity: G P L A and the expected date of delivery.

5. Admission details

   Date and time of admission, emergency or planned, expected length of stay and days in ICU, room type, and the past history of chronic illness — diabetes, heart disease, hypertension, hyperlipidaemia, osteoarthritis, asthma or COPD, cancer, alcohol or drug use, HIV/STD — with the year each began.

6. Cost estimate, by head

   Room rent with nursing and service charges per day, investigations, ICU charges, OT charges, professional fees (surgeon, anaesthetist, consultants), medicines and consumables, implants, other expenses, any package rate, and the total. A single lump figure is the most common reason a pre-auth is queried.

7. Sign, seal and send

   Treating doctor’s signature with registration number, hospital seal, patient’s signature on the declaration. Upload on the provider portal or email to the pre-auth email ID with the documents — within 24 hours of an emergency admission, or 48–72 hours before a planned one as the policy requires.

Documents to send with the form

• Health card / e-card and the patient’s photo ID (Aadhaar, PAN or similar)
• Doctor’s admission advice and consultation notes
• Investigation reports that support the diagnosis
• For surgery: earlier prescriptions showing when the condition was first diagnosed
• For accidents: MLC or FIR copy
• For implants: the estimate with the implant type

Mistakes that get a pre-auth queried

• Duration of illness left blank — the reviewer then suspects a pre-existing disease
• No ICD-10 code, or a code that does not match the diagnosis
• Reports mentioned in the form but not attached
• Cost estimate as one figure, or room category above the policy limit without a note
• Doctor’s registration number or hospital seal missing
• Policy or member number copied wrongly from the card

How fast the answer must come

IRDAI’s Master Circular on Health Insurance Business (May 2024) requires the insurer or TPA to decide a cashless request within one hour, and to give final discharge authorisation within three hours of the hospital’s request. Any extra amount the hospital charges because of a delay beyond three hours is borne by the insurer.

If a query comes back or cashless is denied

Answer a query the same day, with exactly the document asked for. A cashless denial is not a claim rejection: the patient can pay and file for reimbursement, and a rejected claim can be reconsidered through the grievance officer, Bima Bharosa and the Insurance Ombudsman.

Related guides

• Reply to a pre-auth query
• प्री-ऑथ फ़ॉर्म कैसे भरें (हिंदी)
• Cashless claim rejected — for hospitals
• Get a rejected claim reconsidered
• All rejected-claim guides

Who fills the pre-auth form?

Both. The patient or attendant fills and signs the patient section; the treating doctor fills the clinical section, the admission details and the cost estimate, and signs with registration number and hospital seal. The hospital’s insurance desk sends it.

Is ICD-10 code mandatory in the pre-auth form?

The standard form asks for the ICD-10 code of the provisional diagnosis (and ICD-10 PCS for a procedure). Leaving it out is a common reason for a query.

Where do I send the pre-auth form?

To the TPA named on the patient’s health card, or to the insurance company if no TPA is named — through its provider portal or pre-auth email ID.

When should the pre-auth be sent?

Most policies require intimation within 24 hours of an emergency admission and 48–72 hours before a planned admission. Check the policy wording.

How long does pre-auth approval take?

Within one hour of the request, under IRDAI’s 2024 master circular. Final discharge authorisation is due within three hours.

प्री-ऑथ फ़ॉर्म कौन भरता है?

मरीज़ या उसके परिजन मरीज़ वाला हिस्सा भरते हैं, और इलाज करने वाले डॉक्टर बीमारी, ICD-10 कोड, इलाज और ख़र्च का अनुमान भरते हैं।