Designation: Pre-Authorization, Final Bill & Discharge Summary Validation Executive

Role Purpose To ensure accurate, compliant, and timely submission of insurance claims by validating pre-authorizations, final bills, discharge summaries, tariffs, approvals, and supporting documents, thereby minimizing claim rejections, revenue leakage, and manual bill edits.

Key Responsibilities

- Validate Pre-Authorization (PA) requests before submission to Insurance Companies/TPAs.
- Verify patient KYC, insurance card, ID proof, diagnosis, room category, package applicability, LOS, and supporting clinical documents.
- Ensure all required investigations, consultation records, and justification letters for package deviations are available.
- Review final bills to ensure charges, packages, tariffs, discounts, and approvals are applied as per insurer/TPA agreements.
- Validate approval letters and coordinate with IP Managers, Billing Teams, and Insurance/TPAs for necessary corrections.
- Calculate and verify non-medical expenses (NMEs), non-payable items, and patient liabilities, and communicate collection requirements to IP teams.
- Cross-check diagnosis, procedures performed, billing entries,



and discharge summaries for accuracy and compliance.
- Coordinate resolution of insurer/TPA queries and ensure timely claim submissions.
- Monitor Preauth submissions through IHX and other designated portals.
- Conduct pre-discharge billing audits to identify and rectify discrepancies before claim submission.
- Maintain compliance with insurer guidelines, hospital policies, and audit requirements.
- Generate exception reports and recommend process improvements to reduce claim deductions and manual bill modifications.

Key Performance Indicators (KPIs)
- Reduction in manual bill edits.
- Reduction in Preauth rejections and deductions.
- First-time-right Preauth submission rate.
- Accuracy of tariff, package, and approval validation.
- Timely submission of Preauth within SLA.
- Reduction in post-discharge billing corrections.

Expected Outcome Ensure accurate claim processing, improve claim realization, minimize billing errors and deductions, strengthen compliance, and enhance overall insurance revenue management.

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