The Challenge
Before this system, a hospital's insurance desk carried the pre-authorisation and settlement process largely by hand — from pulling patient and diagnosis details out of HIMS, to assigning ICD-10 codes, to catching mismatches between what was billed and what the policy or tariff agreement actually allowed.
Key Challenges
- Manual pre-auth form generation — patient details, diagnosis, and ICD-10 coding had to be pulled from HIMS and entered into pre-auth forms by hand: slow, and prone to coding inconsistency.
- No systematic check against policy or tariff before submission — cash components weren't verified against the policy document and the hospital–insurer Tariff MOU before a pre-auth went out, so mismatches often surfaced only later, at settlement.
- Payer responses tracked ad hoc — approvals, denials, and requests for additional documents arrived by email and had to be manually read, categorized, and acted on, with no structured alert to the insurance desk when something needed a response.
- Settlement mismatches caught late, if at all — without line-by-line reconciliation against each claim, a lower-than-expected settlement or a wrongful disallowance could go unchallenged simply because no one caught it in time.
- No feedback loop — a disallowance reason from one claim had no way of preventing the same mistake on the next pre-auth; each case started from zero.
Our Solution
From Manual Pre-Auth to a Self-Correcting Claims Pipeline
The system integrates directly with the hospital's HIMS and carries a claim from pre-authorisation through settlement reconciliation as one continuous, tracked process — with turnaround time (TAT) monitored at every stage.
HIMS-Integrated Pre-Auth Generation
Patient and diagnosis details are pulled directly from HIMS, ICD-10 codes are assigned, and a pre-auth template is generated ready for signature — removing manual data entry at the point where the process starts.
Tariff and Policy Verification Before Submission
Before a pre-auth goes out, the cash components are checked against the policy document and the Tariff MOU between the hospital and insurer, catching mismatches before they become disputes.
Automated Payer Response Handling
When a pre-auth response arrives by email, the system auto-captures it and categorizes the status — Approved, Partially Approved, Denied, or Additional Documents Required — and alerts the insurance desk directly when documents need to be submitted.
Settlement Reconciliation and Appeal Generation
The same categorization flow applies at settlement: each payment is mapped line by line against its claim. Where a disallowance appears, the system identifies the reason and, where appealable, generates the appeal letter immediately — including cases where the settlement itself came in lower than expected.
Course Correction on the Next Claim
Disallowance reasons feed back into the pre-auth process, so the same mistake is corrected before it happens again — rather than repeating on the next claim.
Key Impact
Because patient and diagnosis details are pulled directly from HIMS instead of entered by hand, pre-auth forms go out four times faster.
Automated coding against HIMS diagnosis data cuts the inconsistency that came with manual ICD-10 assignment.
The Customer
A hospital running its own insurance and claims desk, handling pre-authorisation and settlement across its payer relationships. A different facility from the one running OpBook360, kept as a fully separate case study rather than linked.
The Outcomes
The insurance desk moves from a manual, three-system scramble to a single pipeline that pre-fills, verifies, tracks, and learns — turning every disallowance into a lesson the next claim benefits from.
Pre-Auth That No Longer Starts From a Blank Form
Patient, diagnosis, and coding details arrive pre-filled from HIMS, cutting the manual work that used to open every claim.
Mismatches Caught Before Submission, Not After
Checking cash components against the policy and Tariff MOU upfront means fewer disputes downstream, at the point they're hardest to resolve.
No Payer Response Goes Unanswered
Every pre-auth and settlement response is automatically categorized and routed to the insurance desk, so nothing needing action sits unnoticed in an inbox.
A Claims Process That Learns
Disallowance reasons don't just get appealed — they get fed back into how the next pre-auth is built, so the same denial reason doesn't recur.
Have a Similar Build in Mind?
Bring us the complexity — we'll bring the production-grade platform.
Talk to the founder