If you don’t get pre-authorisation before an in-hospital procedure, your medical aid can reject your claim.
Medical aids in South Africa require pre-authorisation for non-emergency hospital procedures to help keep costs down, the Council for Medical Schemes and Medihelp have told MyBroadband.“Pre-authorisation is a critical component of managed care health services and is permissible in Regulation 15 of the Medical Schemes Act,” a spokesperson for the council said.
“Such as members facing severe acute illness or even the fact that a chronic condition is not fully controlled,” said Medihelp. “Before the procedure can be authorised, physicians adhere to the relevant clinical practise guidelines and standard treatment guidelines relating to refractive surgery,” the Council for Medical Schemes spokesperson said.
“Scheme rules provide members with a late authorisation, subject to a penalty generally stated in the scheme rules,” said the council. “Where the rules of the medical schemes require a pre-authorisation, and this is not done, then such a claim must be rejected,” it stated.
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