APPROVALS AND DENIALS IN NNPC HMO LIMITED – CONTACT CENTRE VIEW

Authorization which means A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary (Preauthorization – HealthCare.gov Glossary https://www.healthcare.gov) is a norm in health insurance. The request may be made prior the utilization of healthcare service – Pre-authorization, or after – Post-authorization. The variation from one health maintenance organization is dependent on what is being approved, how approvals are handled and response time.
In Emergencies, are authorizations required? “Life first, business later!” So, imagine how high the interactions rise when people are agitated over a Provider’s response “we are waiting for approval from your HMO”. Objectively, phone calls are imperative adjuvants to email requests in urgent matters but resuscitation does not require pre-authorization in NHMO because Emergencies are fully covered. In addition, post-approvals with 24-72hours notice are accepted.
In NHMO, we have three forms of approvals namely:
1. Administrative Approvals
2. Management Approvals
3. Code Approvals
Administrative Approvals: Approval statement issued from the Contact Centre to Providers for Managed Care and Third Party Administration (TPA) Clients when the services required are covered. Response time is from 1 minute – 24 hours on the most.
Management Approvals: All requests that cannot be approved from the Contact Centre desk are escalated to the Management. Response time is 1 minute – 24 hours on the most while turnaround time is usually 1 hour – 72 hours on the most.
Code Approvals: All social health approval requests are justified by peculiar codes issued to Providers. Response time is 1 minute – 24 hours on the most.
Authorization requests can either be approved, delayed or denied based on:
1. The availability of complete and correct data such as matching name to policy number
2. Covered service(s)
3. Correct PCP
4. Referral letter/referral code/email
5. Other supporting documents like medical report and bill estimate where necessary.
NB: Denials may be escalated for exclusion management by the affected Client in NHMO Managed Care.
We have had Enrollees assert that Approvals take a long time even when the conditions above are fully satisfied. Yes, they may, depending on the medium of request (Calls, Emails, SMS or WhatsApp) and surge periods. Unfortunately, Enrollees calculate their hospital arrival time into the authorization request time and this is incorrect. The cooperation of our Providers has helped us drive down such complaints as they confirm their request time to the Enrollees.
Some Nigerians have not subscribed to health insurance because they see authorizations as hindrances to timely service. This perception is not unfounded but it is still incorrect.
NHMO is establishing strategies to diminish authorization necessities through:
1. Sensitization of Entities, Providers and Enrollees.
2. Future elimination of approval for services <50,000 for social scheme and <500,000 for managed care.
We must appreciate that a system without control cannot thrive. NHMO will not relent in its efforts at continual improvement because we appreciate that health insurance is one sure way to universal healthcare coverage and authorization of care is one of its residing processes.