Pre-authorisation

Pre-authorisation is required for hospitalisation and for specified in- and out-of-hospital major medical treatment and diagnostics. This includes expensive radiology, oncology treatment, physical rehabilitation, orthodontics and certain other dental procedures, amongst others. Please refer to the Schedule of Benefits for treatment that requires pre-authorisation. It is the member’s responsibilty to obtain pre-authorisation, which should be obtained at least seven days prior to the commencement of treatment or services. In the case of after-hours emergencies, authorisation must be obtained the next working day. Pre-authorisation is based on clinical criteria and is not a guarantee of payment.

Authorised services or treatment must commence within three months of authorisation, after which the authorisation is no longer valid.

If authorisation is not obtained, you may be responsible for a penalty of 10% to a minimum of R2 000 per event.

Profmed does not prescribe the treatment members may choose to have. However, we will only fund treatment that is in accordance with the Scheme rules and protocols and which is clinically appropriate and evidence-based, subject to PMB legislation.

What costs are included in the hospital authorisation?

Hospital authorisation covers only the cost of the hospital facilities, e.g. ward fees, materials, theatre fees, medicines (excluding medicine taken home on discharge). Specialist and GP fees for consultations and procedures and other medical practitioner fees in hospital are not included in the authorisation.

Internal surgical devices and external prostheses and appliances are included in the authorisation, but are reimbursed according to the benefit available to the member in accordance with the option the member has chosen. Quotes for these items must be submitted to the Scheme.

Radiology, pathology and physiotherapy in hospital

In-hospital MRI and CT scans and other investigative procedures as well as phystiotherapy, must be pre-authorised. Hospitalisation is not covered if the admission is for the sole purpose of radiology or pathology investigations.

Pre-authorisation for out-of-hospital treatment

Certain out-of-hospital treatment requires pre-authorisation. Where this treatment is subject to a benefit limit, the claim will be funded in terms of the availability of benefits at the time the claim is received by the Scheme for processing, and in accordance with the benefits provided on each option. Benefits are not reserved when authorisation is granted. Please note, pre-authorisation is required for out-of-hospital MRI, radio-isotope and CT scans.