What is a medical emergency?
A medical emergency is defined in the Medical Schemes Act as “the sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.”
Does Medihelp cover medical emergencies?
If you receive services at an emergency unit for an emergency which fits the definition for a medical emergency as specified in the Medical Schemes Act, the doctor who treated you will certify it as a medical emergency and Medihelp will approve it as a prescribed minimum benefit (PMB) condition.
How do I register an emergency hospital adimission?
Emergencies must be registered on the first workday after the admission. Contact Medihelp Customer Care at 086 0200 678. Remember to have the following info at hand:
- Membership number
- Details of the patient, hospital and doctor
- Diagnostic and procedure codes
- Admission date and time.
What happens if my condition does not qualify as a medical emergency?
If you visit an emergency room and you don’t require life-saving treatment and/or hospital admittance after the ER doctor has examined you, the treatment you receive will be viewed as a visit to an emergency room and not as a medical emergency. The visit will then be covered from the benefits you have available for consultations on your benefit option. In this case, facility fees as charged by the emergency unit will not be covered.
Why does the emergency unit charge facility fees?
Although emergency units are usually situated at hospitals, they are not part of the hospitals. The emergency units are owned by general practitioners and therefore operate like private practices that remain open after hours. Services received at an emergency unit are therefore seen as the same as a regular GP visit.
Will I be liable for facility fees charged by the emergency unit?
If your condition does not fit the definition for a PMB that necessitates immediate life-saving treatment and/or hospitalisation, you will be billed for a normal consultation and for additional fees such as facility fees and after-hours fees that the doctor on call might charge. Medihelp will pay the consultation from the benefits you have available for consultations on your benefit option, but you will be responsible for the additional fees. If you have no benefits available for consultations, you will also be responsible for the consultation fee.
Will I receive benefits for medicine prescribed at the ER?
Registered regular chronic medicine obtained from an ER will be paid from the chronic medicine benefits available on your benefit option.
Acute medicine prescribed to Plus, Elite and Prime range beneficiaries will be paid as follows:
- 100% of the Maximum Medical Aid Price (MMAP) if generic medicine is used
- 80% of the Medihelp Tariff (MT) if original medicine is used when no generic medicine is available
- 70% of the MMAP if original medicine is voluntarily used although generic medicine is available.
If you are a Necesse member and have emergency unit and out-of-network benefits available, you must collect your medicine from a network pharmacy, pay cash and claim it back from Medihelp. The claim will qualify for an 80% benefit and will be funded from your available out-of-network benefits.