necesse (network option)

Important information

Doctors’ visits
You must visit your nominated general practitioner in the Medihelp network. Your general practitioner will refer you to a physiotherapist, specialist and other medical practitioners if required. Please remember to obtain pre-authorisation from Medihelp from your ninth consultation (the family’s visits combined) onwards at your network doctor.

About your claims
Your doctor and other medical practitioners will submit claims directly to Medihelp. If you have paid the doctor’s account yourself, you can submit the claim to Medihelp for a refund should the claim qualify for benefits. Please post, fax or e-mail the following to Medihelp:

• The detailed account
• A copy of your proof of payment
• The authorisation/referral number for the consultation (in the case of a specialist or medical practitioner on referral).

Emergencies
Please remember that only emergencies which meet the definition of an emergency on this brochure (see “Explanation of terms”) will qualify for Prescribed Minimum Benefits (PMB) and must be registered as such with Medihelp.

You can visit your nearest medical facility for a serious medical condition that warrants immediate medical attention if your network doctor is not available (for example in after-hours cases). You may be required to pay for the consultation upfront, and a 20% co-payment applies to emergency and out-of-network consultations which do not qualify for PMB. In these cases, the facility fee does not qualify for benefits. The claim for the consultation and medicine provided as well as proof of payment can be submitted to Medihelp to be considered for funding from the available emergency and out-of-network benefit. Remember to register the consultation with Medihelp within 72 hours.

Non-chronic (acute) medicine
Should you require medicine, your network doctor will provide you with the medicine if he/she is a dispensing doctor, or he/she will provide you with a prescription for medicine listed on the Medihelp formulary. Medicine on prescription must be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network.

Chronic medicine
Only chronic medicine which forms part of the Chronic Diseases List (CDL) will qualify for benefits. Chronic medicine must be registered with MEDICHRON, Medihelp’s chronic medicine benefit management division according to authorisation protocols. Once your network doctor has diagnosed you or your dependants with a chronic illness, he/she will complete an application form to register the chronic medicine with MEDICHRON. As soon as you have received a schedule from MEDICHRON indicating which medicine items have been authorised, you have the choice of either obtaining the authorised chronic medicine on a monthly basis from a pharmacy in the Medihelp Preferred Pharmacy Network, or from a courier pharmacy in the network who will deliver the medicine to an address of your choice (your local post office, home, work or your network doctor’s rooms).

Specialist referral process
Your Medihelp network doctor will refer you to a specialist if required. This entails that your network doctor completes a specialist referral form which will be used to obtain pre-authorisation for the specialist visit from Medihelp. Pre-authorisation can be obtained by e-mailing the form to medihelp@medihelp.co.za, faxing it to 012 336 9540 or phoning 086 0100 678 prior to visiting the specialist. The referral number and authorisation numbers must be indicated on the specialist’s account.

Other referrals
Your network doctor will also refer you to a physiotherapist, occupational therapist, pathologist, radiologist or other medical practitioner if required. Referral numbers must be indicated on the accounts.

Hospital admissions
Your Medihelp network doctor or the specialist to whom you were referred will decide whether you should be admitted to hospital. All hospital admissions, including for psychiatric admissions, must be pre-registered (and emergency admissions on the first workday following the admission). Phone Medihelp on 086 0200 678 with the following information:

• Your membership number
• The patient’s name and date of birth
• Your contact details
• The reason for admission (procedure and diagnostic codes – your doctor can provide these)
• The date of the admission
• The doctor/specialist’s name and practice number
• The hospital’s details

What we don’t pay for

Medihelp excludes the following from benefits, except in the case of statutory Prescribed Minimum Benefits (PMB):

General

• Services which are not mentioned in the Medihelp Rules as well as services which are not aimed at the generally accepted medical treatment of an actual or a suspected sickness or handicap, which is harmful or threatening to necessary bodily functions (the process of ageing is not considered to be a sickness or handicap).
• Travelling and accommodation costs, including meals as well as administration costs of a member and/or service provider.
• Aptitude and intelligence tests.
• Operations, treatments and procedures – 
  • of own choice;
  • for cosmetic purposes; and 
  • for the treatment of obesity, with the exception of the treatment of obesity which is     motivated by a medical specialist as life-threatening and approved beforehand byMedihelp. 

• Treatment of wilfully self-inflicted injuries, unless it is a Prescribed Minimum Benefit.
• The treatment of infertility, other than the following treatment (according to PMB code 902M), subject to pre-authorisation by Medihelp: 
  • Hysterosalpinogram. 
  • The following blood tests:  
    • Day 3 FSH / LH; • Prolactin; • VDRL;  
    • Oestradiol; • Rubella; • Chlamydia; and  
    • Thyroid function (TSH); • HIV; • Day 21 progesterone. 
  • Laparoscopy. 
  • Hysteroscopy. 
  • Surgery (uterus and tubal). 
  • Manipulation of ovulation defects and deficiencies. 
  • Semen analysis (volume, count, mobility, morphology, MAR-test). 
  • Basic counselling and advice on sexual behaviour, temperature charts, etc. 
  • Treatment of local infections.
• The artificial insemination of a person as defined in the National Health Act, 2003 (Act No 61 of 2003).
• Immunisation (including immunisation procedures and material) which is required by an employer.
• Bandages, cotton wool and plasters on prescription that are not used by a supplier of service during a treatment/procedure.
• Services which are claimable from the Compensation Commissioner, an employer or any other party, subject to the stipulations of rule 15.4.
• Treatment of alcoholism and drug abuse as well as services rendered by institutions which are registered in terms of section 21(2) of the Abuse and Dependence-producing Substances  and Rehabilitation Centres Act, 1971 (Act No 41 of 1971) or other institutions whose services are of a similar nature, except in the following instance when alcohol and drug abuse will be considered as a Prescribed Minimum Benefit:

• Exercise, guidance and rehabilitation programmes.
• Treatment of impotence.
• Treatment of occupational diseases.
• Services rendered by social workers.
• Completion of medical and other questionnaires not requested by Medihelp.
• Costs for evidence in a lawsuit.
• Costs of visits at home and home programmes.
• Costs exceeding the scheme tariff for a service or the maximum benefit limit to which a member is entitled, subject to Annexure 2 of the Rules.
• Food substitutes, food supplements and patent food, including baby food.
• Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics).
• Slimming remedies, provided that benefits shall be considered if motivated by a medical specialist as life-essential to be used for a limited period, and if approved beforehand by the Principal Officer.
• All patent substances, suntan lotions, anabolic steroids, contact lens solutions as well as substances not registered by the South African Medicines Control Council, except in the case of medicine items approved by Medihelp in the following instances –
  • medicine items with patient-specific exemptions in terms of section 21 of the Medicines  and Related Substances Control Act, 1965 (Act No 101 of 1965) as amended; and
  • where well-documented, sound evidence-based proof exists of efficacy and cost effectiveness.
• When only accommodation and/or general care services are rendered.
• The cost of transport with an ambulance/emergency vehicle –
  • from a hospital/other institution to a residence;
  • in the event of a self-inflicted injury, unless it is a Prescribed Minimum Benefit;
  • in the event of a visit to friends/family; and
  • to the rooms of a medical practitioner when the objective of the visit/consultation/treatment does not pertain to admission in a hospital.
• The cost of harvesting and/or preserving human tissues, including, but not limited to, stem cells, for future use thereof to treat a medical condition which has not yet been diagnosed in a beneficiary.
• Breast augmentation.
• Breast reduction.
• Gastroplasty.
• Gender reversal operations.
• Lipectomy.
• Epilation.
• Otoplasty/reconstruction of the ear.
• Refractive procedures.
• All biological and other medicine items as per Medihelp’s medicine exclusion list.
• Hip, knee and shoulder replacements.
• Hymenectomy and circumcision.
• Removal of impacted wisdom teeth during hospitalisation.
• Roaccutane and Retin A, or any skin lightening agents.
• Services rendered to beneficiaries outside the Medihelp network, except for those services as listed in Schedule B6 or if voluntarily obtained from a non-designated service provider in the case of a PMB condition.
• Injuries sustained during participation in a strike, unlawful demonstration, unrest or violent conduct, except in the case of a Prescribed Minimum Benefit.
• Homeopathic and herbal medicine, as well as household remedies or any other miscellaneous household product of a medicinal nature.
• Insulin pumps and related consumables.
• Back and neck fusion procedures, subject to PMB.
• Facility fees.
• Standard immunisation.
• Contraceptive agents.

Dental service exclusions

• Oral hygiene instructions and oral hygiene evaluation.
• Nutritional and tobacco counselling.
• Caries susceptibility and microbiological tests.
• Electrognathographic recordings and other such electronic analyses.
• Fissure sealants on patients older than 16 years.
• Replacement of amalgam (silver) fillings with composite (white) fillings.
• Gold foil restorations.
• Pulp capping (direct and indirect).
• Polishing of restorations.
• Ozone therapy.
• Metal base to full dentures, including the laboratory cost.
• Crown and bridge procedures for cosmetic reasons and the associated laboratory costs.
• Diagnostic dentures and the associated laboratory costs.
• Provisional crowns and the associated laboratory costs.
• Emergency crowns that are not placed for immediate protection in tooth injury, and the associated laboratory costs.
• Resin bonding for restorations charged as a separate procedure.
• Dental bleaching.
• Porcelain veneers and inlays and the associated laboratory costs.
• Orthodontic treatment for cosmetic reasons.
• The auto-transplantation of teeth.
• The closure of an oral-antral opening when claimed during the same visit with impacted teeth.
• Where the reason for admission to hospital is dental fear or anxiety.
• Where the only reason for admission to hospital is to acquire a sterile facility.
• Perio chip.
• The hospital and anaesthetic claims for the following procedures will not be covered when performed under general anaesthesia:
  • Apicectomies. 
  • Dentectomies. 
  • Frenectomies.
  • Soft tissue impactions.
  • Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for  adults.
  • Professional oral hygiene procedures. 
  • Implantology and associated surgical procedures.
  • Surgical tooth exposure for orthodontic reasons.
  • Removal of impacted wisdom teeth unless covered by bone.
• Orthognathic (jaw correction) surgery and the related hospital cost, and the associated laboratory costs.
• Sinus lift procedures.
• Bone augmentations.
• Bone and other tissue regeneration procedures and the cost of material.
• Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis.
• Surgical periodontics which includes gingivectomies, periodontal flap surgery, tissue grafting and hemisection of a tooth.
• Orthodontic re-treatment and the associated laboratory costs.
• The cost of dental materials for procedures performed under general anaesthesia.
• Dolder bars and associated abutments on implants, including the associated laboratory costs.
• The laboratory costs, where the associated dental treatment is not covered.
• The laboratory cost associated with mouth guards. The clinical fee will be covered at the Medihelp Dental Tariff where clinical protocols apply.
• Snoring appliances and the associated laboratory costs.
• High-impact acrylic.
• Cost of mineral trioxide.
• Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments.
• The cost of gold, precious metal, semi-precious metal and platinum foil.
• Cost of invisible retainer material.
• Cost of bone regeneration material.
• Appointments not kept.
• Professionally applied topical fluoride in adults.
• Laboratory delivery fees.
• Special reports.
• Dental testimony.
• Enamel microabrasion.
• Behaviour management.
• Intramuscular and subcutaneous injections.
• Procedures that are defined as unlisted procedures.
• The clinical fee for the addition of a soft tissue base to new dentures. The laboratory fee will be covered at the Medihelp Dental Tariff where clinical protocols apply.
• The clinical fee for denture repairs and denture tooth replacements. The laboratory fee will be covered at the Medihelp Dental Tariff where clinical protocols apply.
• Multiple hospital admissions.
• Full mouth rehabilitations and the associated laboratory costs.

Denis dental protocols

Fillings

• For extensive restorative treatment (multiple fillings) a treatment plan and X-rays may be requested.

Hospitalisation (general anaesthetic)
General anaesthetic benefits are only available for very young children for extensive dental treatment. The hospital and anaesthetist claims for the following procedures will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits, and payable at the Medihelp Dental Tariff:

• Soft tissue impactions
• Apicectomies
• Dentectomies
• Frenectomies
• Implantology and associated surgical procedures
• Conservative dental treatment (fillings, extractions and root canal therapy) for adults
• Professional oral hygiene procedures
• Surgical tooth exposure for orthodontic reasons