🏥 Healthcare · Sequence
Cashless Hospitalisation Pre-Authorisation
How a cashless health insurance claim works at a hospital: pre-authorisation with the TPA, treatment, and final bill settlement directly with the insurer.
Drawing diagram…
What this diagram shows
- Hospital requests approval from the TPA before planned treatment
- Enhancement requests cover costs that grow during the stay
- The patient pays only non-covered items at discharge
Prompt used
Cashless claim sequence: the patient shows the health card at admission, the hospital's insurance desk sends a pre-authorisation request with diagnosis and estimated cost to the TPA, the TPA checks the policy with the insurer and approves an amount, treatment happens, the hospital sends an enhancement request if costs rise, at discharge the final bill is sent, the TPA approves the final amount, and the patient pays only non-covered items.
Mermaid code
sequenceDiagram actor Pt as Patient participant H as Hospital Insurance Desk participant TPA as TPA participant Ins as Insurer Pt->>H: Admission with health card H->>TPA: Pre-auth request (diagnosis, estimate Rs 1.2 L) TPA->>Ins: Check policy cover Ins-->>TPA: Covered, sum insured Rs 5 L TPA-->>H: Approved Rs 1.2 L Note over H: Treatment H->>TPA: Enhancement request Rs 30,000 TPA-->>H: Enhancement approved H->>TPA: Final bill and discharge summary TPA-->>H: Final approval Rs 1.45 L H-->>Pt: Pay non-covered items only TPA->>Ins: Settlement to hospital
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