FAQ'S
Frequently Asked Questions.
1. HOSPITALISATION
We cover each procedure according to the benefits available on your option plan. If you need to go to hospital, you must contact our pre-authorisation department to confirm your admission to hospital. We will explain how your procedure will be covered. The contact can be made via call, email or our online chat. Use of DSP is very important to avoid co-payments.
What is Pre-authorisation?
If you or a member of your family is to be admitted to hospital, you must contact KeyHealth at least 48 hours before you are admitted to obtain an authorisation from the scheme.
In the case of an un-planned, un-scheduled or emergency admission, you must contact the scheme within 48 hours after admission.
When is pre-authorisation required?
- Pre-authorisation is required for planned hospital admissions, MRI/CT scans, chronic medication, etc and other major medical expenses as specified in the Benefit guide.
- If you do not obtain pre-authorisation prior to incurring expenses for these specified events, you may be exposed to unfunded liabilities (penalties or out-of-pocket payments), or you could even be liable for the full account in case you accessed benefits of which you are excluded from.
- It is therefore vital that you obtain pre-authorisation where indicated as a requirement in your benefit schedule, before incurring any expenses.
What information is required when calling for pre-authorisation?
Before calling for a hospital pre-authorisation, you will need to have the following information available:
- Name and contact details of main member.
- Initials, surname, and date of birth of the patient (main member or dependant).
- Membership number.
- Name and practice number of treating doctor.
- Name and practice number of hospital where you will be admitted.
- The reason for the admission (i.e. the diagnosis or procedure).
- The date of admission and the expected date of discharge.
- ICD-10 (diagnosis) code – remember to ask your doctor for this.
- CPT4 (procedure) code – remember to ask your doctor for this.
Please make sure that you record your pre-authorisation number and be sure to hand it to the admissions desk when you are admitted to hospital.
Why do I need to obtain pre-authorisation for planned hospital admissions?
- Pre-authorisation also gives you an opportunity to find out what your available benefits for the procedure or treatment are.
- To consider the benefits of using a network provider and to plan for any out-of-pocket expenses. You can also request a cost quotation at this stage.
- Getting the necessary authorisation ensures that your claims will be settled correctly.
- To receive additional clinical advice relating to your treatment, which might have been omitted during your consultation with the admitting doctor.
What if I am admitted to hospital in an emergency?
- For an emergency admission, you or the hospital must call for pre-authorisation. Business hours are from 07:00 to 18:00 during the week.
- If it’s not possible to call during business hours, you still have 48 hours from the first business day following the admission to obtain authorisation.
- Getting the necessary authorisation ensures that your claims will be settled correctly.
- In an emergency admission, we don’t expect you to look for a network service provider, given that your time will be limited.
- Prescribed Minimum Benefit claims will be covered in full, while claims that are not classified as Prescribed Minimum Benefits will be covered at the Scheme Rate.
Pre-authorisation for a MRI, CT scan
- An MRI (or magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves and a computer to produce images of body structures. MRI scans are painless and do not involve X-ray radiation.
- A CT scan is imaging using special X-ray equipment to produce multiple images of the inside of a body. CT scans are used to examine internal organs, bone, soft tissue, and blood vessels.
- A separate authorisation is required for the scans even if someone is already in hospital and has obtained an authorisation for the hospital admission.
- Admission in hospital will not be granted if the reason for admission into is solely to do a scan. For babies and patients who are mentally challenged to follow instructions, a hospital admission maybe considered in order for them to be sedated before a scan can be performed.
It is essential that you obtain pre-authorisation before an MRI, or CT scan is performed.
Before calling for authorisation, you will need to have the following information available:
- Name and contact details of main member.
- Initials, surname, and date of birth of the patient (main member or dependant).
- Membership number.
- Name and practice number of treating doctor.
- Name and practice number of Radiology where you will have the scan done.
- The reason for the scan (i.e. the diagnosis or procedure).
- ICD-10 (diagnosis) code – remember to ask your doctor for this.
2. EMERGENCY MEDICAL CONDITION
What is an emergency medical condition?
- An emergency medical condition means a sudden illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm. The unexpected onset requires immediate medical treatment and/or an operation, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or would place the person’s life in serious jeopardy, or even death.
- If doctors suspect that the patient suffers from an emergency condition that is not possible to diagnose before admission for treatment, the medical scheme will approve admission and request that the diagnosis be confirmed with supporting evidence within a reasonable period.
Examples of some emergency medical conditions
- Heart attack symptoms.
- Stroke symptoms.
- Choking incident.
- Heavy bleeding – loss of blood can be life-threatening.
- Severe head injury.
- Problems associated with diabetes, and chronic medical problems, etc.
What must I do if there is an emergency in my family?
- Take your family member to the nearest casualty service and present your MEDICAL AID card and or your emergency ER Card.
NB: (only child dependants have an ER card, adult dependants use the normal medical aid card). Your emergency treatment will be covered according to your Option’s benefits.
- Call the Netcare 911 Emergency on 082 911 or 080 111 0215, which provides quick and professional advice if you are unsure or are interested in self-help care.
- If you require ambulance services, call emergency Netcare 911 on 082 911 at any time of the day or night to obtain authorisation for emergency transportation. Explain the situation so they can determine the type of advice and transport required. Try to be calm and give all details so they can be able to assist you.
- Alternatively, go straight to the emergency room yourself – but get someone to call us within 12 hours if you are admitted to the hospital. It is important that you, a loved one or the hospital let us know about your admission as soon as possible so that we can advise you on how you will be covered for the treatment you receive.
- If your medical condition requires transportation to a hospital, we will cover the cost to transport you to the nearest hospital and the cost of treatment in the hospital’s emergency or casualty unit subject to funds available. Please note that the scheme does not cover the costs of transportation from the emergency room/hospital back home once the member has been treated.
- If you are in an emergency and you are taken to hospital, you will be stabilised, and care rendered subject to your clinical needs. If the hospital is a non-DSP, you will not need to be transferred to a DSP hospital and the account will be paid in full as an emergency case.
- We’ve got you! We will cover the cost of the admission and all the associated healthcare providers’ costs while you’re in a hospital. A benefit limit applies, and pre-authorisation is required.
3. CLAIMS STATEMENT
Your claims statement is one of the most important documents. Check your claims statement carefully to help us to detect fraud and to manage your healthcare benefits efficiently. Please check your statement to ensure that the claims on the statement are for services that you and/or your registered dependants received.
Who should submit the claim, the member, or the Service Provider?
- In most cases, this depends on your provider of service. Many service providers submit their accounts to the medical scheme directly, in which event you will not need to submit the account as well.
- However, in instances where the service provider does not submit the account directly, it will be your responsibility to ensure that the scheme reaches the medical scheme before the cut-off date.
- We recommend that you talk to your doctor and reach agreement with him about who will be required the account to the medical scheme.
Important information that must be contained on your account?
- Your name and surname.
- Your medical scheme number – is very important.
- The name of the patient that was treated (as reflected on your membership card).
- The name and practice number of the doctor.
- The service date or treatment date treatment.
- The tariff code and the amount charged per tariff code.
- The Nappi code of each item of medication claimed and the amount charged per Nappi code.
- The ICD-10 code per treatment item.
How do I submit an account for a claim?
- KeyHealth app: Upload an image of your claim and submit via the app – ensure to download the app via Google Play or the Apple store.
- KeyHealth website: Scan and upload your claim as a PDF document utilising the link available on the KeyHealth website.
- Email to: Scan and e-mail your claims to general@keyhealthmedical.co.za.
- Post to: You can submit your claim via post by sending it to PO Box 14145, Lyttleton 0140.
Remember that you have up to four months to submit your claim to the scheme – that is from the date of treatment. Claims received after this month’s deadline will be regarded as stale and will not be paid. If your healthcare professional has sent us the claim, you do not need to send us another copy. Please keep that copy for your records.
What happens if information on my claim is missing or unclear?
The claim will be rejected with a “Reason code”. There is a column on your claim statement that will indicate the reason for the rejection. It is important to read the description provided for every reason code on your claims statement, as you may be required to submit additional information before we can pay the claim.
I paid cash at my service provider. How do I claim that amount back from the scheme?
- Please get a detailed account from the service provided (i.e. it must contain principal member details, patient details, date of service, tariff codes for services rendered, provider’s practice number etc.
- The detailed account, together with proof of payment must be submitted to the Scheme.
- This will then be processed and if it is a valid claim and there are sufficient benefits available, it will be refunded to the member.
How do I submit a claim for refund?
- KeyHealth app: Upload an image of your claim and submit it via the app – ensure to download the app via Google Play or the Apple store.
- KeyHealth website: Scan and upload your claim as a PDF document utilising the link available on the KeyHealth website.
- Email to: Scan and e-mail your claims to general@keyhealthmedical.co.za.
- Post to: You can submit your claim via post by sending it to PO Box 14145, Lyttleton 0140.
4. MEDICAL SAVINGS ACCOUNT (MSA)
Medical Aid Savings (MSA) is a percentage of your annual scheme contribution held in a separate account and used to pay for your day-to-day medical expenses like doctor visits, X-rays, and dentist visits. Any money in your MSA that you haven’t used by the end of the year is carried over to the next year.
How do medical aid savings work?
- At the beginning of the year or when you join a medical scheme, you have access to the amount allocated in your medical savings account, which is available separate from your day-to-day benefit pool.
- If you leave a medical scheme before the end of the year or choose to change to a plan without a savings account, the scheme will calculate how much of the savings you have used and how much you have already contributed to the account.
- If you have used more than you have contributed, you will need to refund the difference to the scheme. Once your savings are used up, your day-to-day benefit will be used for any out-of-hospital medical expenses.
Can you withdraw medical aid savings?
You cannot withdraw money from your allocated Medical Savings Account (MSA), but we will pay any positive balances from your allocated MSA if:
- You have resigned from the Scheme.
- You have downgraded your health plan to a plan that does not offer an allocated Medical Savings Account.
Important information
- Members may not use savings to pay co-payments incurred for treating PMB conditions.
- Medical schemes may not use savings account to pay for claims related to PMBs.
- The balance of the savings will be transferred to another medical scheme if a member joins a benefit option that has a medical savings component.
- If you have used more than you have contributed, you will need to refund the difference to the scheme.
Example: The Scheme affords a member an advance savings of R6000 at the beginning of the year which means a member must pay R500 monthly contribution towards his savings, and if the member leaves the Scheme in June having used all his savings, he will be liable to refund the Scheme R3000.
5. CHRONIC DISEASES AND DISEASE RISK MANAGEMENT
What is a chronic disease or condition?
- A chronic disease or condition is that which usually lasts for 3 months or longer and may get worse over time. Chronic conditions require ongoing medical attention as they tend to limit activities of daily living.
- Chronic diseases occur mostly in older adults but are also common in younger population. Chronic conditions can usually be controlled but not cured.
- The most common types of chronic diseases are hypertensive heart disease, diabetes mellitus, asthma etc.
- Chronic diseases such as hypertensive heart disease, diabetes mellitus, chronic obstructive airways disease are the most leading causes of death and disability in SA.
- Disease risk management (DRM) is a unique programme that assists members to help manage their chronic conditions effectively and to improve the well-being of affected members.
What is chronic medication?
- Chronic medication includes medicine used to treat disabling chronic illnesses that significantly affect your quality of life.
- This Chronic Disease List (CDL) is a prescribed minimum benefits list that ensures all medical aid schemes fund the cost of the diagnosis, medical management (consultations and procedures) and medication of a specified list of chronic conditions.
- There are 27 (CDL) conditions that, by law, must be covered by all schemes and on all their options.
- Additional conditions, over and above the PMB’s are covered on the selected/more comprehensive options subject to Scheme decisions.
I have been given a general waiting period on my medical aid. Will I be able to get my chronic medication?
- Medical aid schemes in South Africa may impose certain waiting periods on new members and/or their dependants when joining a medical scheme.
- A waiting period protects the Scheme by making sure the new members cannot make large claims shortly after joining and then cancel their membership of the scheme again.
- According to the Medical Schemes Act, medical aid schemes are entitled to impose a 3-month general waiting period and / or a 12-month condition specific waiting period(s) for any pre-existing medical condition(s).
- The Act makes specific provision for the imposition of waiting periods (and late joiner penalties). This is done to protect the current membership pool of medical schemes from selective abuse. In other words, schemes are offered some protection from people that only join a medical scheme when they require medical attention.
- During this period, members must pay their normal monthly contributions, but are not entitled to claim any benefits whatsoever, except in certain instances with claims relating to PMBs.
- FOA (Freedom of association) members needs to ask doctor to register their chronic condition with MK immediately after joining the scheme.
Please see the detail in the below summary of the provisions applicable to waiting periods as per the Medical Schemes Act:
CATEGORY | 3-Months General Waiting Period | 12-Months Conditions Specific Waiting Period |
New applicants who are currently members of another registered SA Medical Scheme for more than 2 years, and / or who have not cancelled their membership for more than 90 days preceding the date of application. | Yes | No |
New applicants who are members of a registered SA Medical Scheme for less than 2 years. | No | Yes |
New applicants, or applicants who are not members of a registered SA Medical Scheme for at least 90 days preceding the date of application. | Yes | Yes |
Change of benefit options. | No | No |
Child dependants born during the period of membership. | No | No |
How do I have my chronic medication approved?
- If a patient is diagnosed with one of the chronic conditions listed in table 1, 2 or 3, then registration of the chronic condition involved is required before access to the chronic medication benefit will be granted.
- No authorisation forms are involved, as this is a paperless process, unless there are specific test results and / or a motivation required.
- Only new condition registrations require the doctor or pharmacist to intervene.
- Chronic conditions, already registered with the Scheme, require no action at the start of the new benefit year, as existing chronic conditions will automatically remain registered.
- The treating doctor or the pharmacist (after the initial consultation with the doctor) must register chronic conditions with MediKredit on 0800 132 345, as detailed clinical information, including the condition’s ICD-10 code and severity status, is required.
- The doctor’s prescription will then authorise the patient to obtain the chronic medication from a local pharmacy or the doctor’s dispensary.
- Certain products can only be authorised if prescribed by the appropriate specialist. These specialists must contact MediKredit on 0800 132 345 for further information.
How do I obtain my approved chronic medication?
Once approved, the member can then obtain their chronic medication at any dispensing pharmacy.
How often do I need to obtain a repeatable prescription?
- A prescription cannot be repeated for more than six months according to law. The Pharmacy of choice should remind you (in writing, via SMS or telephonically) to provide a new prescription from your doctor one month before your last repeat is sent out.
- The Pharmacy will not provide you with further medication if your prescription has expired, and you have not submitted a new one.
- The medical aid will pay for chronic medicines prescribed according to the medicine formularies applicable to your option subject to the Scheme rules.
What if my chronic medicine request has been declined?
If your chronic medicine request has been declined, your doctor or pharmacist who phoned for authorisation will be informed during the call. You can obtain the medication from your savings or day-to-day benefit.
What if my authorised chronic medication changes?
- If your chronic medication changes in any way, your medical aid needs to be advised. The quickest way is for the prescribing doctor or dispensing pharmacist to contact the scheme’s Chronic Medication Department.
- If approved, a new repeatable prescription must be provided to the DSP who will then dispense the medicine.
How to register for Chronic Illness Benefit?
- Chronic Medicine: 0800 132 345 (To be used by providers).
- HIV Management: 00860 50 60 80 8860.
- Oncology management: 00860 671 060.
- Disease Risk Management: 0860 671 060.
- DRM email: Disease.management@keyhealthmedical.co.za.
- Oncology email: Oncology@keyhealthmedical.co.za.
What are the benefits of registering on the Disease Risk Management (DRM) Programme?
- Proper risk management and integration of preventative healthcare services to members with the objective of promoting self-management and better control of chronic conditions.
- Members benefit the most when the health risk is identified early, and the intervention is at an early stage.
- Those who register and adhere to the programme protocols get better clinical and health outcomes.
