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The pre-auth clock nobody is watching

24 hours for an emergency admission, 72 for a planned one. Miss it and a cashless admission quietly becomes a reimbursement claim.

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Hospitals6 min readUpdated 2026-07-08

Most Indian TPA and insurer contracts carry a notification requirement that is separate from the pre-authorisation itself: the hospital must inform the payer that an admission has happened, within a fixed window. Commonly 24 hours for emergency admissions and 72 hours for planned ones.

Miss it and the claim is usually not rejected outright. Something worse happens — the admission loses cashless status and converts to reimbursement. The family pays at discharge and claims it back themselves, over months. From the hospital's side the money still arrives, eventually, from the patient rather than the payer. From the family's side, the hospital promised cashless and did not deliver.

Why it gets missed

The clock starts at admission, which is a clinical event. The notification is an administrative one, usually owned by the TPA desk, which is not staffed at 2 a.m. when the emergency admission happens. By the time the desk opens, eight of the twenty-four hours are already gone, and the case sits in a queue with everything else that arrived overnight.

The notification window, from admission to conversion The clock starts at admission, a clinical event. Notification is administrative and belongs to a desk that is not staffed overnight, so an emergency admission at 2am loses a third of its window before anyone opens the file. Emergency windows are commonly 24 hours and planned admissions 72, though these are contractual and vary by payer. Escalating early, at a fraction of the window, prevents a failure. Escalating at hour 22 of 24 only reports one. Past the window the admission does not get rejected: it loses cashless status and converts to reimbursement, and the family pays at discharge. Emergency admission · commonly 24 hours 0h admission 8h desk opens 22h 24h desk unstaffed — a third of the window escalate here Planned admission · commonly 72 hours 0h admission 24h 72h escalate inside day one Past the window not a rejection cashless becomes reimburse- ment An alert at hour 22 of 24 reports a failure. It does not prevent one. Windows are contractual and vary by payer — 24 and 72 are common, not universal.

Illustrative of the mechanism, not of any hospital’s data. Window lengths are contractual and vary by payer.

Nobody is negligent. There is simply no clock on the screen.

What a working notification process looks like

  • The clock starts automatically at admission, not when someone opens the TPA file
  • The window is per-payer, because they differ — do not hard-code 24 hours across every contract
  • Escalation happens at a fraction of the window, not at expiry. An alert at hour 22 of 24 is a notification of failure, not a prompt
  • The submission is blocked if it is incomplete, with the missing item named — an incomplete notification sent inside the window is not a notification

The enhancement request, which has the same problem

A pre-authorisation is approved for an amount. The stay extends, or a procedure is added, and the billed total crosses the approved figure. The enhancement request has to go before the crossing, not after.

The enhancement threshold, at 85 per cent and at 100 A pre-authorisation is approved for an amount. If the stay extends or a procedure is added, the billed total crosses that figure and an enhancement request has to be approved before it does. Flagging at 85 per cent of the approved amount leaves room for the request to be worked. Hospitals in practice discover the problem at 100 per cent, when the bill has already reached the approved figure, and by then the enhancement still needs time it no longer has. Billed total against the approved amount 85% 100% approved and unspent flag here — the request still has room to be worked discovered here — already late The enhancement must be approved before the bill crosses the approved figure, not after.

Illustrative. The approved amount is whatever the pre-authorisation set; the percentages are of that figure.

In practice hospitals discover this at 100% — when the bill hits the approved amount. That is already late, because the enhancement takes time to approve. The threshold worth alerting on is closer to 85%, which leaves room to request, wait, and receive a decision before the ceiling is actually reached.

What to check this week

Pull the last three months of admissions that converted from cashless to reimbursement. For each one, find the admission timestamp and the notification timestamp. If the gap exceeds the payer's window in more than a handful of cases, the problem is structural, not individual — and it is worth fixing with a clock rather than a reminder.

Drapto tracks notification windows per payer from the admission event and flags enhancement requests at 85% of the approved amount. See the pre-authorisation layer →

Written for Indian practices

Every figure here uses Indian policy mechanics, Indian payers and Indian clinical vocabulary. Nothing on this blog is translated from a US or UK playbook.

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