Why is Pre-authorisation necessary?
Pre-authorisation for hospital admissions and certain out-of-hospital care is a key component in managing your access to affordable, appropriate, safe and quality health care. Medscheme’s pre-authorisation requests are adjudicated against clinical and funding guidelines as well as set criteria in recognising healthcare providers who are able to perform certain procedures. Once you are pre-approved, the healthcare provider and hospital account will then be paid according to your selected benefit option and available benefits.
When do you need to contact us for pre-authorisation?
- Any procedure or treatment that clinically requires admission to hospital
- Specialised radiology in- and out-of-hospital (MRI and CT Scans)
- Oncology Treatment
- Renal Dialysis
- Clinically appropriate home nursing, admission to a step-down facility and rehabilitation
- Maternity admissions and confinements
How do I Pre-authorise?
Call 0860 33 33 87 (preferably 72 hours before the procedure is performed) and provide the following information:
- Membership number
- Patient’s name, surname and date of birth
- Doctor’s name and practice number
- Name of hospital
- Procedure to be performed and ICD-10 code(s)
- Date of admission
What if I’m diagnosed with Cancer?
- A SAMWUMED Oncology case manager will provide support and guidance that will continue throughout your treatment.
- As soon as you and your team of doctors agree on a treatment plan, ask your doctor to forward it to the SAMWUMED Oncology Management Programme. An Oncology case manager will review the plan, discuss it with your doctor and advise on the outcome of your application.
- You will then receive an authorisation letter for the authorised treatment. If there are certain items that are not covered, you will need to discuss this with your doctor.
- Please ensure that your doctor informs the SAMWUMED Oncology Management Programme of any change in your treatment, as your authorisation will have to be re-assessed and updated accordingly to ensure that your claim(s) are not rejected or paid from the incorrect benefit.
What happens in an emergency?
Don’t worry. In the case of an emergency situation you or a family member may pre-authorise the admission on the first working day after being admitted.
What is a PMB?
Prescribed Minimum Benefits (PMB) is a set of defined benefits that ensure you have access to certain minimum health services, regardless of the benefit option you have selected. In accordance with the Medical Scheme’s Act, medical schemes have to cover the costs related to these conditions which include:
- Any emergency medical admission
- A limited set of 270 pre-defined medical conditions
- Twenty-five (25) chronic medical conditions
- Your doctor will guide you in determining whether your condition falls into one of the PMB conditions. It is vital that you obtain a pre-authorisation for any PMB condition as your scheme may require you to be referred to a designated service provider so that all associated costs are in line with SAMWUMED’s Scheme Rules.
What is Case Management and Care Co-ordination?
While you are in hospital, our case managers will ensure that the appropriate length of stay and level of care is provided at all times and that appropriate discharge planning takes place. Medscheme also focuses on care co-ordination to improve the quality of care that you receive while in hospital, and to improve your health status after you are discharged. The benefit of this is that, with your consent, we will share information about your condition, well-being and health within the different managed health care departments as well as with your nominated doctor.
Co-ordinating your care is done through various interventions from preadmission to eight weeks after you are discharged so that you receive the best health care; reduce your chances of re-admission and encourage you to take responsibility for your own health. Through care co-ordination you will receive a pre-admission hospital checklist (depending on your type of admission) that will assist you in preparing for hospitalisation and post discharge recovery. You will also be referred to various managed care services and appropriate healthcare providers as and when required.