Pre-authorisation is important

Before you have any medical procedure or hospital admission, you need to get authorisation. This will help you establish exactly what is covered and whether you need to plan for any out-of-pocket expenses. The pre-authorisation process also ensures that you will have your claim paid correctly.

What is pre-authorisation?
All procedures that take place in a hospital must be pre-authorised. Essentially, it’s an agreement between the medical aid and the hospital, indicating a willingness to pay for costs associated with the visit. All pre-authorisation requests are evaluated against the Fund Rules and clinical funding policies.

Pre-authorisation is not the same as a quote.
It is important to obtain pre-authorisation but to also ask for a detailed quote from the hospital and medical practitioner prior to being admitted to hospital. It is important to find out what the medical aid will pay and what you might be responsible for.

When is pre-authorisation needed?
You must apply for a pre-authorisation reference number (PAR) before you have any medical procedure or before being admitted to hospital. A good time to do this is 48 hours in advance.

The following information is required when you request a pre-authorisation for a procedure:
Name and surname of the patient, Membership number and dependant code, The date of admission or procedure, The diagnosis, All proposed procedure codes available (ICD-10, CPT, NRPL codes), The name of the facility where the procedure will take place, The names and practice numbers of the healthcare professionals (doctor, surgeon, etc.)
Pre-authorisation can be obtaind by phoning your Scheme call centre or sending an email.
Scheme Call Centre and email

What about emergency admissions?
In the event of emergency treatment or admission to hospital you must contact the call centre on the first working day after the incident. If you cannot contact your scheme, a family member or the hospital can do so on your behalf.

What happens if you don’t get pre-authorisation?
In most cases, the procedure will not be covered or will attract a co-payment.

Did you know?
Your doctor or the facility you are being admitted to can do the authorisation on your behalf. But remember, it remains your responsibility to ensure that the authorisation is correct.

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