Pre-authorization

What is pre-authorization?

This is the process whereby you notify the scheme that you are about to be hospitalized or that you want to access benefits for which pre-authorization is required. Services and treatments that require a pre-authorization is indicated on the benefit options. The scheme will confirm what benefits and amount of benefit that is available.

For what do I need pre-authorization?

• Any hospital admission (including Psychiatric hospitalization)

• Procedures in doctor’s rooms

• Rehabilitation

• Maternity benefits

• MRI/CT Scans and radio isotope studies, interventional radiology and specialized radiology

• Access to Chronic and HIV/AIDS Medicine Benefit

• Dental surgery and specialized dentistry

• Refractive Surgery

• Basic dentistry in hospital for children under the age of seven

• Services and treatment as indicated on benefit options

 

How is pre-authorization obtained?

Pre-authorization is obtained by contacting the Scheme on 362 4700. Please have your membership number at hand.

Your service provider may also request pre-authorization on your behalf.

The service provider needs to provide the diagnosis; the intended treatment and estimated cost in writing as verbal pre-authorization will not be permitted. This is subject to assessment.

A pre-authorization number will be issued for the specific event as listed above or indicated in the benefit structure upon approval.

 

Failure to acquire pre-authorization?

If a member needs emergency treatment outside of working hours or on the weekend then pre-authorization can be requested on the next working day.

Claims submitted without pre-authorization will be rejected whether the claim is payable to the member or the service provider.

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