Pre-authorisation for Hospitalisation
Authorisation needs to be obtained within 24 hours prior to an admission, or within two (2) working days after an emergency admission (family members, friends or the hospital can call on behalf of the Beneficiary if he/she is unable to), otherwise a penalty will be applicable. This penalty will be deducted from the Member’s hospital account.
Information needed for Authorisation
The following information must be provided when calling:
- Membership number.
- The full name and surname, and dependant code of the patient being hospitalised.
- The name and practice number of the hospital to which the patient will be admitted.
- The reason for the hospital admission:
- Admission diagnoses or ICD-10 code.
- If admission is for planned surgery, all relevant procedure (tariff) codes.
- CPT4 codes, if available.
The practice number of:
- The treating Doctor/Specialist.
- The referring Doctor/Specialist.
- Other service providers (if applicable).
- Alternatively, the initials, surname, and telephone number of both treating and referring Doctor/Specialist.
Please note
- Only medically appropriate claims will be covered by the Scheme and authorisation does not guarantee that all associated costs of the authorised procedure will be paid.
- Benefits will be paid according to what is permitted in terms of the Scheme Rules, funding guidelines and clinical protocols.
- Services must commence within thirty (30) days of approval and will be subject to the available benefits of the year in which the services are rendered.
- The Beneficiary enjoys the benefits for as long as the hospitalisation of the case involved has been authorised. Before and after hospitalisation, the Beneficiary receives out-of-hospital benefits.
- Certain in-hospital expenses incurred as part of a planned procedure may not be covered by a Member’s hospital benefit.
- Certain procedures done, medication and new technology used in-hospital may require separate authorisation. Members are requested to clarify this with their Medical Practitioner prior to admission to the hospital.
- Should Members receive accounts requesting additional payments for hospitalisation, kindly contact the Client Service Centre on 0860671050 for verification prior to making payments.
