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Hospital Risk Management

The programme ensures that you receive appropriate, quality healthcare while you are hospitalised. The pre-authorisation process ensures that the planned procedure or treatment is both necessary and appropriate.

The rules of the Scheme require you to obtain pre-authorisation before any of the following:

  • All planned hospital admissions
  • Admissions for mental health and drug or alcohol dependency
  • Confinements (childbirth)
  • CT, MRI and radioisotope scans
  • Dental surgery and all dental services that require admission
  • Hospital admission for basic dentistry for children under the age of eight years (the dentist will be paid from the advanced dentistry benefits)
  • Organ transplants.

What is pre-authorisation?

  • Pre-authorisation is the process whereby you notify the Scheme that you are about to be hospitalised (State or private hospital).
  • This means that you must contact the Scheme for any planned hospitalisation, as well as for certain procedures performed in doctors’ rooms, e.g. a gastroscopy, colonoscopy or vasectomy.
  • Only hospital treatment and procedures that are medically necessary will be pre-authorised.
    If you do not obtain pre-authorisation, you may not receive benefits for these services.
    When you are admitted to hospital for treatment that is medically necessary, you will be covered under MME benefits, provided that you follow the pre-authorisation and approval process. It is important to note that the Scheme reserves the right to exclude benefits in respect of services which, in its opinion, do not necessitate hospitalisation.

PLEASE TAKE NOTE OF THE FOLLOWING IMPORTANT POINTS:

  1. Ensure that you understand the reasons for your admission to Do not hesitate to approach your doctor about the procedure or procedures you need to undergo.
  2. Make sure that you understand your benefits and what is available prior to If you have any questions related to your benefits, please contact the MEDiPOS Client Service Department on 0860 100 078
  3. Always confirm whether the doctor charges medical scheme rates prior to treatment. If the doctor charges above medical scheme rates, you will be liable for the
  4. Leave all your valuables at home before being admitted to hospital.
  5. Pre-authorisation must be obtained at least three working days prior to a non-emergency admission.
  6. In the event of an emergency admission or admission over a weekend, pre-authorisation must be obtained 24 hours after admission or on the next working
  7. If an extended length of stay is required following the initial pre-authorisation, the hospital is required to submit clinical information for
  8. If possible, ensure that you are discharged from hospital before 12:00 to ensure that no additional charges are added to your hospital account. Discharge after 12:00 with no clinical motivation will not be covered by the

How to obtain pre-authorisation:

 The pre-authorisation process is designed to be both quick and informative. The entire pre-authorisation process can be finalised within five minutes. In the case of an emergency, the member or hospital should contact us within 24 hours of the event or on the next working day. In the case of a late or no pre- authorisation being obtained, you will be responsible for a co-payment of R2 000.

Make sure you have the following information readily available:

  • Your Scheme membership number
  • ID number of the main member (without this, the Scheme cannot load the authorisation – required for security reasons)
  • The name and telephone number of the doctor who wishes to admit you to hospital
  • The ICD-10 code/s obtained from the admitting doctor
  • The proposed treatment or procedure
  • The planned date of admission to the hospital
  • The name and practice number of the hospital you will be admitted
  • In the case of an emergency, where you or a dependant are admitted directly to hospital,
  • A family member must notify the Scheme within 24 hours or on the first working day following

Dental Benefits

 All dental treatment for specialised dental procedures and procedures to be done in hospital (general anesthesia), require pre-authorisation before treatment.

Which procedures require pre-authorisation?

 Below is a list of all dental procedures that require pre-authorisation:

  • Orthodontic treatment – all types of orthodontic treatment require pre-authorisation
  • Crowns and bridges
  • Inlays and onlays
  • Indirect veneers
  • Metal-based dentures
  • Periodontal surgical management
  • Maxillofacial and oral surgery
  • All phases of dental implants
  • All dental treatment performed in hospital

All requests for dental admissions must be submitted to dental@medipos.co.za or faxed to 086 763 2155.

Upon confirmation of your benefits, you will receive Acknowledgement of Benefits
letter with your pre-authorisation number.
You must give this number to the hospital when you are admitted.

 

IF FURTHER INFORMATION IS REQUIRED

  • The admission request or procedure is queried with the hospital.
  • A letter of motivation is requested from your doctor.
  • Your doctor’s motivation is referred to our medical advisor for consideration and will be finalised within 48 hours, excluding weekends.
  • Our medical advisor grants or denies pre-authorisation.

AUTHORISATION IS GRANTED

You are notified of the decision and are required to liaise
with your doctor regarding the date for the procedure.

AUTHORISATION IS DENIED

You, the hospital or your doctor is informed that preauthorisation has been denied.

Please remember that it remains your responsibility to discuss costs with your doctor. If your
doctor charges fees outside the agreed tariff, you will be liable for the difference.
Please note that should you be admitted to a non-network hospital, you may be liable for a copayment/penalty

CHECKLIST FOR HOSPITAL ADMISSION

Before Admission: Prepare, before you need to go in
  • Advise your family practitioner of your medical condition and admission to hospital and confirm his or her role in the process and after you are
  • Go through any details and any communication from your admitting doctor, the hospital and the medical scheme and take note of the pre-authorisation letter MEDiPOS has sent to you.
  • Confirm with your admitting doctor and the hospital if you need to pay anything extra on admission or after your For instance, if your doctor charges tariffs in excess of the medical scheme rate you may have to pay an additional amount.
  • Check your member guide or ask the pre-authorisation agent whether you need to make use of the MEDiPOS doctor or hospital network, as this can mean you may have extra co-payments.
  • Go through your benefit guide and read about the relevant benefit sub-limits, particularly if you are having an operation that will need a prosthesis. This will help you to understand any co-payments.
  • Discuss with your admitting doctor whether you will need assistance when you get home and arrange this before you are admitted.
  • Prepare your house for when you get You may need to rearrange furniture or buy supplies.
  • Make sure your admitting doctor and anaesthetist are aware of any allergies or health conditions you may have and of any medicine, including supplements and herbal treatments, that you are currently taking.
  • Pack your chronic medicines to take with to the hospital as you may need to continue to take them while you are in hospital, confirm this with your admitting
While in Hospital: Do this when you are close to being discharged
  • Make sure your family members are up to date with your
  • Chat to the nurses about what to expect and how to manage when you are at home, including any instructions on medicine or wound care you may need.
  • Check with your treating doctor if you need to start any new chronic medicine or if there will be any changes to your existing
  • If there is any medicine that you will need to take home, check with the doctor for any contra-indications or interactions with other medicine you are taking.
  • Make sure your follow up appointment with your treating doctor or family practitioner is confirmed before you leave the (If you had an operation, the 6 week follow-up visit is included in the fee payable to your surgeon, therefore no additional cost)
When discharged
  • If you need to update or add new chronic medicines, submit your prescription to your pharmacy to ensure you receive your updated Your pharmacy will interact with us, if necessary.
  • If you have had surgery, keep an eye on symptoms like abnormal pain, wounds that are red or painful or infected or developing a high fever. Contact your treating doctor or family practitioner immediately if you are unsure.
  • Make sure that you go to any follow up appointments with your doctor and ask all the questions you may have on how to get better and manage your 
  • A Case Manager from MEDiPOS may call you to check on your progress, see if you need any help and check that you are taking your prescribed medicine.