All about authorisation

The Benefit Guide specifies, for every benefit, whether you need an authorisation to access the benefit. We usually refer to 'authorisation', but authorisation can be either preauthorisation or retrospective authorisation. Pre-authorisation is to be obtained before planned procedures in hospitals, day clinics and doctor's rooms, including tests such as MRI and CT scans and inter-hospital ambulance transfers, to mention a few. Retrospective authorisation can be given for an event that has already occurred. This event would have required authorisation, but it could not have been, for various reasons, obtained at the time. Without authorisation, the payment of the healthcare services will be rejected for 'no authorisation', or paid from your day-to-day benefits, even if you have a benefit for these services. Some Scheme-specified procedures will be considered for payment from the Scheme 'Risk', not from your limited benefits or MSA. Other procedures might need a retrospective review as they are initially not considered as payable from 'Risk'.

What happens in the case of emergency?

The Medical Schemes Act 131 of 1998 defines an "emergency medical condition" as "the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a body organ or part, or would place the person's life in serious jeopardy", i.e. a heart attack, stroke, a motor vehicle accident, broken femur after a fall, etc.

To get authorisation for a medical emergency, call us the next working day or within 48-72 hours. We will assess the circumstances and advise whether the event will be authorised.

Authorisation rules to note:

• Authorisation for a hospital admission is only valid for 4 months
• You can't get an authorisation for a hospital admission or procedure for the following year
• Unless specifically indicated, an authorisation for benefits will only be valid for the current year as benefits and co-payments can change from year to year
• Always ask which benefits will be used for your authorised event. Authorisation does not mean 'payment (in full) by the Scheme'. Benefit rules, limits and co-payments still apply

Claims procedures:

If your claim was rejected for 'no authorisation', call us to find out what information we need to consider retrospective authorisation. If you think your claim was paid from the wrong benefit, i.e. the Medical Savings Account or limited benefits, ask us for a re-evaluation.

Authorisation vs registration:

Your benefit guide also shows if you need to register your condition for your claims to be paid from a dedicated benefit. If you don't register your condition, claims will be paid from your limited benefits or MSA.

For both authorisations of healthcare services and registrations of conditions, or any question you might have on the topic, please call us on 0860 222 633.

Published: January 2023.