Going to see a healthcare provider
Our Administrator constantly engages with the relevant representative bodies to look at ways of enhancing professional relationships to the benefit of all parties. The Administrator looks to do this without compromising our fundamental principles.
The healthcare funding industry needs to carefully balance the needs of all the key role players - namely healthcare providers, members, and the Scheme.
You can benefit by using healthcare providers who are in our network because the Scheme will cover their costs in full (within the available limits of your relevant benefits).
However, if you choose not to use the DSPs, the Scheme will cover the cost of your treatment up to 100% of the Scheme Tariff.
Healthcare providers who participate in the network are also Designated Service Providers (DSP) for Prescribed Minimum Benefits and payment will be made as stated above. However, if you choose not to use the DSPs, the Scheme will cover the cost of your treatment up to 100% of the Scheme Tariff. To gain a comprehensive understanding of the PMB coverage for in-hospital and out-of-hospital services, please refer to the respective guides provided below:
Click here for your In-hospital PMB guide.
Click here for your Out-of-hospital PMB guide.
General practitioners (GP)
A general practitioner or GP is a medical practitioner who gives primary care and specialises in family medicine. A general practitioner treats acute and chronic illnesses and provides preventive care and health education for all. They have particular skills in treating people with multiple health issues.
If your GP sees you out of hospital
We pay for eight consultations per beneficiary per year with your PGP. Consultations with a GP who is not the nominated PGP, will attract a 20% deductible co-payment. You can access the find a healthcare provider tool to search for the healthcare providers.
Medical specialists
A specialty in medicine is a branch of medical science. After completing medical school, physicians or surgeons usually add to their medical education in a specific specialty of medicine by completing a multiple year residency. Medical practitioners who take on a medical specialty are known as medical specialists.
Cover for out-of-hospital specialists is unlimited, subject to referral from your GP and a 20% deductible member co-payment. An additional 20% deductible member copayment will apply if a patient consults a specialist out of hospital without a GP referral.
Cover for in-hospital specialists is unlimited, subject to an associated hospital pre-authorisation being in place. You can access the find a healthcare provider tool to search for the healthcare providers in our network.
Dentists
Dentistry is the known evaluation, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity and maxillo-facial area. This includes the adjacent and associated structures and their impact on the human body.
How we cover dentistry
The Scheme examines claims according to clinical appropriateness using relevant dental coding and tooth numbers, where applicable. Claims will not be paid for treatment that seem to be conflicting with your dental history or if the Scheme rules do not allow certain procedures. In such a case, your dentist will be asked for additional information, an amended account, or be sent a reason for the non-payment of the claim.
Please click here to read more about cover for dental treatment as cover for some treatments is subject to preauthorisation, limits and/or co-payments.
Other (allied healthcare providers)
Allied healthcare providers are clinical healthcare providers other than medicine, dentistry, and nursing. They work in a healthcare team to make the healthcare system function.
In-hospital
In-hospital services that have been specifically authorised as part of an approved hospital admission are not subject to the allied health and alternative healthcare services benefit limit and do not attract a 20% deductible co-payment. These healthcare services will be covered up to 100% of the Scheme Tariff.
Out-of-hospital
The allied health and alternative healthcare services benefit is limited to R5 000 per beneficiary, and further limited to R7 500 per family, per annum. We pay claims for allied health and alternative healthcare services at 100% of the Scheme Tariff. Members are responsible for a 20% deductible co-payment.
X-rays
X-rays are photographs or examinations of body parts made by electromagnetic radiation.
The way we pay for x-rays depends on whether you have the x-ray in-hospital or out-of-hospital.
X-rays done in-hospital
We pay for the x-ray up to a maximum of the Scheme Tariff if it is related to your confirmed hospital admission.
X-rays done out-of-hospital
These claims are unlimited and paid up to the Scheme Tariff.
MRI and CT scans
Who may refer you for a MRI or CT scan
Please note: All MRI and CT scans must be referred by a specialist.
We will only approve scans that have been referred by an appropriate specialist. We will fund MRI or CT scans which are appropriately referred by a GP during an emergency hospital admission from the Specialised Radiology limit, subject to preauthorisation.
In-hospital
We pay approved MRI and CT scans performed during an approved hospital admission from the Specialised Radiology limit if the scan is related to the reason for the admission.
Out-of-hospital
We pay the account from the Specialised Radiology overall limit, up to 100% of the Scheme Tariff.
Other scans
Mammograms
A mammogram is an x-ray examination of the female breast. It uses low-energy x-rays to visualize fine details of breast tissue, particularly the presence of calcification or soft tissue masses. This enables the early diagnosis of breast cancer.
Mammograms done out-of-hospital
We will pay for one mammogram annually from your Preventative Care Benefit.
Pregnancy scans
Ultrasound imaging allows imaging of the interior of the human body. The advantages of ultrasounds versus x-rays, are that the patient is not exposed to potentially harmful radiation. Images that can't be seen by x-rays are visible through ultrasound imaging.
A maximum of two 2D scans are covered during the pregnancy.
We will pay these claims from your Maternity Management Programme, if you have registered and have benefits available.
Blood tests
A blood test is any test designed to discover abnormalities in a sample of a person's blood, such as the presence of alcohol, drugs, or bacteria or to determine the blood group.
Important notes about blood tests
The way we pay for blood tests depends on whether you have the blood test in-hospital or out-of-hospital.
Blood tests done in-hospital
We pay for the blood tests unlimited, up to a maximum of the Scheme Tariff if it is related to your confirmed hospital admission.
Blood tests done out-of-hospital
We will pay these claims from your Pathology limit of R5 500 per beneficiary and up to the Scheme Tariff.
Endoscopies
What are endoscopies?
Endoscopies - also called scopes - are used to investigate certain medical and surgical conditions such as gastric ulcers, reflux, and infections. When we refer to endoscopies and how we cover them, we only refer to four diagnostic endoscopies which include gastroscopy, colonoscopy, sigmoidoscopy, and proctoscopy. These are all used to investigate the digestive system. Scopes may also be used to investigate other body systems. All such endoscopies/scopes fall outside of this benefit.
Cover for gastroscopy, colonoscopy, sigmoidoscopy, and proctoscopy.
Please note: Please call us to confirm your benefits at least 48 hours before having this procedure.
Where the scope is performed in your healthcare providers rooms we refer to this as "out-of-hospital".
Where the scope is performed in hospital, payment for this healthcare service is based on your network option.
In-hospital
Scope codes will be funded unlimited, subject to pre-authorisation.
Out-of-hospital
Scope codes will be funded unlimited, subject to pre-authorisation. Deductible member co-payments on out-of-hospital GP and specialist consultations will be waived where these non-surgical procedures and tests are performed in healthcare provider's rooms.
Cover for planned hospital admissions
We cover you in hospital for emergency and planned hospital admissions. In an emergency, go straight to hospital but call us or get someone to call us on the first working day after your admission. For planned hospital admissions, please call us 48 hours before you go to hospital to confirm your admission.
Before you go to hospital for any planned procedure, you must:
- See your healthcare provider
- Call us on 0860 002 134 to confirm your hospital admission at least 48 hours before you go to hospital
When you contact us, give us the following details:
- Membership number
- Date you will be admitted to hospital and how long you will stay
- Date of the procedure
- Name of the hospital or clinic
- Admitting healthcare provider's name, practice number and phone number
- Diagnosis (ask your healthcare provider for the ICD-10 diagnosis code)
- The procedure name
- If one of your dependants is admitted, give us their details
- There is no overall hospital limit on either network options
- Limits apply to some healthcare services and procedures
Cover is subject to our rules
We pay medically appropriate claims. Your cover is subject to our Scheme rules, funding guidelines and clinical rules. There are some expenses that you may incur while you are in hospital that your benefit does not cover, for example private ward costs. Certain procedures, medicines or new technologies need separate confirmation while you are in hospital.
Cover for Prescribed Minimum Benefits
For Prescribed Minimum Benefits, we pay hospital admissions for a defined list of 271 diagnostic treatment in full at our DSPs.
How we cover childbirth
We cover childbirth, including home births done by midwives with valid practice numbers and who are appropriately registered with the Board of Healthcare Funders. Please preauthorise childbirth admission, whether at the hospital or for a home birth. Remember to register your baby with us as soon as possible so we can cover the baby.
There are certain limits for childbirth benefits:
|
Childbirth service |
Limit |
|
Normal vaginal deliveries |
A stay of three days and two nights in hospital |
|
Caesarian sections |
A stay of four days and three nights in hospital |
How we cover your healthcare providers in hospital
Your healthcare providers accounts are separate from the hospital account. Healthcare provider accounts may include specialist accounts and other related accounts, for example accounts from a surgeon, anaesthetist, pathologist, or radiologist.
For your planned hospital admissions, we will pay your specialist accounts up to 150% of the Scheme Tariff. Related accounts such as radiology, and physiotherapy will be covered up to 100% of the Scheme Tariff. For pathology Sasolmed has a Designed Service Providers (DSP) namely Ampath, Lancet, Pathcare and Vermaak and partners. Pathology claims will be paid in full at the contracted Tariff for providers we have an agreement with and up to 100% of the Scheme Tariff where we have no agreement in place. If your healthcare provider bills more than the Scheme Tariff, you will be liable to pay the difference from your own pocket.
If your healthcare provider is a provider participating in the network, he or she will be covered in full. You can access the find a healthcare provider tool to search for the healthcare providers who participate in the network.
Benefits
All admissions are subject to prior authorisation
Note: Discovery and the Scheme's in-hospital clinical protocols will be applied
|
Hospital Benefit |
The limit on this benefit |
|
Admission for a Non-Prescribed Minimum Benefit (Non-PMB) |
|
|
Admission for a Prescribed Minimum Benefit (PMB) |
|
|
Emergency evacuation (road or air) |
|