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General topics

Do you have a question about how to make a medical aid claim or how you’re covered by your medical scheme? Find answers to these and many more topics here.

Plans

Medical aid plans explained

What is the difference between a network and non-network medical aid plan?

A network plan gives you access to a network of quality private healthcare providers with whom the medical scheme has contracted agreements. This is a more affordable option, since tariffs are usually more in line with those of the scheme and you have less out-of-pocket expenses, provided you make use of network healthcare providers. These options are also called efficiency discounted options or EDO's.

A non-network plan allows you to visit any healthcare provider of your choice. This means that you have the freedom of choice to go to your preferred GP, hospital or any other healthcare facility. (Note: For certain services, such as oncology or dental services, you will still have to use the medical scheme’s preferred providers.)

What is a medical aid savings account?

At the beginning of the year or when you join Medihelp, you have access to your full medical savings account funds in a separate account from which your day-to-day medical expenses are paid. The funds in this account earn interest during the year, with any unused funds which accumulate, carried over to the next year. Should you terminate your Medihelp membership, your savings will be paid out in full once accounts have been settled (terms and conditions apply). If you are on Medihelp’s Prime 2 or Unify plans, a medical savings account will form part of your benefits.

Does Medihelp have a medical aid plan for students?

Yes: Our Necesse Network student plan is an affordable medical aid for full-time students. You get quality cover at private hospitals, GP’s and other healthcare facilities that fall within the Necesse network. This option also gives you basic dental benefits, cover for medical emergencies and nine GP visits per year, among other benefits.

What is a hospital plan?

A hospital plan offers quality cover for private hospitalisation and minor day-to-day medical expenses at an affordable price. Medihelp’s Prime 1 hospital plan offers this as well as unlimited cover at all private hospitals in South Africa should you be hospitalised due to an accident, illness or medical emergency. Save 22% in monthly premiums when choosing the Prime 1 network plan with 115 quality private hospitals as an alternative.

What does added insured benefits mean?

Added insured benefits offer additional cover and are available on all Medihelp plans. The benefits vary for different options and can include flu vaccines, pregnancy and baby-related benefits, screenings, preventive and wellness services, and a back treatment programme.

Membership

Answers to common Medihelp membership questions

Underwriting conditions


What are late joiner penalties?

Late joiner penalties apply if beneficiaries haven’t been members of a medical scheme before, or if there were prolonged lapses in their previous medical scheme membership.

How do I find out more about late joiner penalties?

Call our Customer Care centre on 086 0100 678, or send email to Medihelp at enquiries@medihelp.co.za.

What are waiting periods?

Waiting periods are periods during which beneficiaries are members, but they do not yet qualify for benefits. It may be for a specific medical condition or a general waiting period. Medihelp may apply two types of waiting periods:

  • A general waiting period of up to three months from the date that you joined. During this time, you will not be entitled to any benefits except prescribed minimum benefits (PMB). If you submit claims during this waiting period, they will not be paid by the Scheme.
  • A condition-specific waiting period of up to 12 months from the date that you joined. During this time, you will not be entitled to benefits for a particular condition for which you were recommend to receive, or for which you received, medical advice, diagnosis, care or treatment (this excludes PMB).

What are “enrolment conditions”?

Upon joining Medihelp, members receive a document with the conditions under which they are enrolled as beneficiaries of the Scheme, indicating any waiting periods and/or late joiner penalties.

Dependants


Who can I register on my medical aid?

You can register any of the following as your dependants at Medihelp Medical Scheme if you’re responsible for their family care and support:

  • Your spouse
  • Your life partner – whether of the same or opposite gender
  • Your children – whether natural, stepchildren, adopted or foster children, or a child in your temporary safe care
  • Your parents
  • Your siblings
  • Your grandchildren.

When will they become active members?

New dependants, namely your spouse, child, grandchild, adopted child or foster child, can become active as dependants on your medical aid immediately. Newborns must be registered within 90 days of the event.

Other dependants may be enrolled either on the day Medihelp receives the application, or on a future date that you request. Please note that the enrolment of a dependant can’t be backdated.

Did you know: On Medihelp’s Prime range you only pay for two children younger than 18 years; the rest receive free medical aid cover. You also only pay child dependant rates for your children until they are 26 years old.

 

What is the maximum age that my child can qualify for child dependant rates?

Children pay child dependant rates until they are 26 years old, unless otherwise indicated on your benefit option.

 

How do I register my dependants?

Use one of the following ways:

On which Medihelp plan can I register my dependants?

All dependants will be registered on the same Medihelp plan as the principal member. In other words, a dependant will always have the same medical aid cover as the main member (as specified in your chosen benefit option).

Tax certificates


I need my medical aid tax certificate to submit my tax return. Where can I find it?

You can download your medical aid tax certificate by logging in to Medihelp’s Member Zone. Alternatively, call our Customer Care centre on 086 0100 678 or email us at enquiries@medihelp.co.za.

What information does my medical scheme tax certificate reflect?

  • Your contributions to the Scheme from 1 March to the end of February of each year
  • Medical claims not paid by the Scheme
  • The total interest you’ve earned on any positive balances in your Medical Savings Account (applicable to the Prime 2 and Unify plans )
  • A monthly breakdown of the main member and all active dependants' contributions.

How do I get a detailed list of all claims appearing on my medical aid tax certificate?

You can phone Medihelp’s Customer Care centre on 086 0100 678, or email us at enquiries@medihelp.co.za to get an itemised list of your claims.

Can Medihelp make changes to my medical aid tax certificate if I request it?

Medihelp unfortunately can’t make any changes to your tax certificate once it has been issued to you.

Updating personal info


How do I update my personal details?

    You can use any of the following ways to update your details:

  • Use our smartphone app for members, available on iStore, Google Play Store and Windows Store.
  • Log in to Medihelp’s Member Zone. On the home page, click on “Details” and then “Personal details”.
  • Call our Customer Care centre on 086 0100 678.
  • Email us at membership@medihelp.co.za.

What personal details should I always keep updated?

  • Marital status
  • Cell phone number
  • Email address (NB: to receive important Medihelp communication)
  • Banking details.

How do I change my banking details?

You can do this online by downloading and completing this form. Please email the completed form together with all required documents to membership@medihelp.co.za.

Medihelp's banking details


What is Medihelp’s banking details?

Medihelp Medical Scheme
Bank: ABSA
Branch: Arcadia
Account type: Cheque
Account number: 61 00 000 88
Branch code: 632005
Ref: Your Medihelp membership number

Please email proof of payment to receipts@medihelp.co.za.

Membership cards


I am a new member. Where can I find my Medihelp membership card?

  • With Medihelp’s member app for smartphones, you always have access to your membership card – and you can quickly share it electronically when needed. Available on iStore, Google Play Store and Windows store.
  • As soon as you become a Medihelp member, we provide you with a membership card that we post to your preferred address.
  • You can also view and/or download a pdf document by logging in to Medihelp’s Member Zone.

What information is featured on my membership card?

Your card contains your unique membership number and the benefit option you are on. It also shows your membership status, your dependant code/s, the date that you enrolled, your card’s issued date, and the date that you can start claiming benefits (if a waiting period applies).

How do I request a new printed membership card?

Please contact our Customer Care centre on 086 0100 678 to request a new membership card. In the meantime, you can still use your digital membership card on Medihelp’s member app available on iStore, Google Play Store and Windows Store. You can also request it by logging in to Medihelp’s Member Zone.

Pre-authorisation

Selected health services and procedures require to be pre-authorised to avoid out-of-pocket expenses.

Members can apply for pre-authorisations on the following platforms:


Medihelp’s Member Zone

All relevant forms are available on the Member Zone.

Medihelp mobile app for members

Available on iStore, Google PlayStore and Windows Store.

Contact us

Medihelp Call Centre: 086 0100 678

Please see the list for all the email addresses, phone and fax numbers.

Contact us

All hospital admissions

All hospital admissions must be pre-authorised, and emergency admissions must be authorised on the first workday after the admission. On Prime 1, 2, 3 and Necesse network plans, network hospitals apply.

Hospital admissions include admissions to state and private hospitals, day clinics as well as psychiatric facilities. Phone Medihelp on 086 0200 678 to get approval for your admission, but request approval for dentistry performed in hospital by emailing our dental benefit management partner, Dental Risk Company (DRC), at auth@dentalrisk.com or visit their website at www.dentalrisk.com.

Log in to Medihelp’s Member Zone to pre-authorise your admission fast and easy. Alternatively, use any of the following ways:

Required information

  • Membership number
  • Details of the:
    • patient
    • admission, procedure and diagnostic codes (you can get these from your treating doctor)
    • doctor
    • practice number
    • hospital

More information

  • Hospital admissions should be registered well in advance
  • If not pre-authorised, a 20% co-payment will apply on the hospital benefit amount
  • Emergency admissions must be registered on the first workday after admission
  • Voluntary admission to a non-network hospital will result in an additional 35% co-payment on the Prime and Necesse Network options
  • Standard co-payments apply to certain procedures (please refer to the product brochure)

Alternatives to hospitalisation

Private nursing, hospice services and sub-acute care as an alternative to hospitalisation


Required information

  • Membership number
  • Procedure and diagnostic codes
  • Doctor’s motivation
  • Quotation for the services of the facility
  • Details of the:
    • patient
    • doctor
    • practice number
    • facility

More information

  • Authorisation will be considered only if required as an alternative to hospitalisation, according to Medihelp’s protocols.
  • Please phone in advance to allow enough time for the authorisation process
  • If not pre-authorised, a 20% co-payment on the benefit amount may apply
  • Benefits do not include frail care services

Prescribed minimum benefits (PMB)


Required information

  • Membership number
  • Details of patient
  • Completed PMB registration/pre-authorisation form
  • ICD-10 code
  • Procedure code(s)

More information

  • PMB conditions must be registered and pre-authorised to qualify for PMB
  • Hospital admissions for PMB conditions must also be pre-authorised at 086 0100 678
  • Emergency admissions must be authorised on the first workday following the admission

Specialised dentistry

  • Dental procedures in hospital under anaesthesia
  • Dental procedures in the dentist’s rooms under conscious sedation
  • Crowns and bridges
  • Orthodontic and periodontal treatment
  • Implants

Dental Risk Company (DRC)

Required information

  • Membership number
  • Item and procedure codes
  • Details of the:
    • patient
    • dentist
    • practice number
    • hospital
    • anaesthetist

More information

Pre-authorisation must also be obtained from DRC for hospital admission where extensive dental treatment is performed under general anaesthesia or where impacted teeth are removed.

Emergency transport services


Netcare 911

082 911

Required information

  • Membership number
  • Details of patient

More information

  • Netcare 911 is Medihelp’s preferred provider for emergency transport services
  • Comprehensive benefits are available for members residing in South Africa, Mozambique, Botswana, Lesotho, Namibia and Swaziland. Necesse members only qualify for these benefits if they reside in South Africa.
  • A 50% co-payment applies if not pre-authorised

Chronic and PMB chronic medicine


Required information

  • Membership number
  • Details of patient
  • Completed forms

More information

Non-PMB chronic medicine (only applicable to members of the Elite and Plus plans)

Your doctor will have to complete certain sections of the chronic application form

PMB chronic medicine

  • Please complete a PMB chronic application form, especially the sections about entry criteria. Forms are available on Medihelp’s Member Zone, or phone our Customer Care centre on 086 0100 678.
  • PMB for a condition on the Chronic Diseases List (CDL) will only apply from the date on which the PMB application was finalised.

Medicine supply for more than 30 days


(NB: Applies to authorised chronic and PMB chronic medicine only)

Required information

  • Membership number
  • Details of patient
  • Completed “Medicine in advance” application form

More information

Please obtain pre-authorisation before obtaining medicine, or notify us before travelling abroad.

Specialised radiology

MRI, CT and PET imaging (PET imaging for members of the Plus option only)


  • Tel: 086 0200 678
  • Fax: 012 336 9523

Required information

  • Patient's membership number
  • Details of patient
  • Details of the radiologist
  • Date of service
  • Item and procedure codes
  • ICD-10 codes

More information

  • All CT and MRI imaging, as well as PET imaging (in the case of Plus), must be pre-authorised. If not, these scans will be excluded from benefits.
  • Angiography does not require pre-authorisation.

Oxygen

Not during hospitalisation


Required information

  • Membership number
  • Details of patient
  • Doctor’s motivation/prescription

More information

Oxygen that is not administered during hospitalisation must be pre-authorised. If not, a 20% co-payment will apply.

Oncology

Cancer treatment programme (within ICON)


Prime network options

Oncology medicine: Designated service provider (DSP)

Dis-Chem Oncology

OR

Medipost

Required information

  • Membership number
  • Details of patient
  • Completed ICON/oncology application form including ICD-10 codes

More information

  • Oncology must be obtained:
    • within the Independent Clinical Oncology Network (ICON), and
    • according to the ICON treatment protocol
  • Co-payments will apply if the above is not followed
  • Oncology treatment must be pre-authorised by Medihelp

HIV/Aids programme

All information will be treated confidentially


Disease management programme

LifeSense


Medicine

Dis-Chem Direct

OR

Medipost

Required information

  • Membership number
  • Details of patient

More information

    Comprehensive benefits are offered for the treatment of HIV/Aids, including:
  • antiretroviral therapy, and
  • post-exposure prophylaxis (PEP)

Important: If you believe you have been exposed to HIV, please obtain PEP from any doctor within 72 hours after exposure.

Medical procedures obtained abroad

Not applicable to members of the Necesse Network option


Required information

  • Membership number
  • Details of patient
  • Date of service
  • ICD-10 code of a similar local procedure
  • Doctor’s motivation

More information

  • These services must be pre-authorised by Medihelp
  • If approval is granted, benefits are paid according to the applicable tariff payable for a similar service in South Africa
  • Members receive 90 days’ emergency cover
  • PMB is not applicable abroad
    • Tip: Take out international travel insurance

Optometric services

  • Optometric examinations
  • Spectacles or contact lenses

Preferred Provider Negotiators (PPN) optometry network

More information

You can phone PPN with any questions regarding your optometry benefits.

Claims

Answers to your medical aid claim questions.

What are ICD-10 codes?

ICD-10 codes are diagnostic codes that healthcare providers use to inform medical schemes about what conditions their members were treated for so that claims can be settled correctly.

What is the difference between generic and original medicine?

After the patent rights on original medicine have expired, pharmaceutical companies may use the same active ingredients in the same dosage as the original, but under a different brand name. Using generic medicine reduces your out-of-pocket expenses.

How do I reduce or avoid medicine co-payments?

  • Visit a pharmacy in the Medihelp Preferred Pharmacy Network.
  • Use generic medicine, paid at 100% of the Maximum Medical Aid Price.
  • Use only authorised PMB medicine, paid at 100% of the Medihelp Reference Price.

What can I see on my Medihelp claims statement?

  • Claims and benefits received for the month
  • Services claimed by healthcare providers
  • Co-payments (if applicable)
  • Benefit pool (e.g. savings) from which benefits were paid
  • Any amounts rejected and reasons why
  • Summary of your benefits

How do I know whether a medical aid claim was paid?

Call our Customer Care centre on 086 0100 678, or log in to Medihelp’s Member Zone and search under “Claims” on the homepage.

How do I submit a medical claim to Medihelp?

Some healthcare practitioners may require you to pay their accounts first and then claim a refund from Medihelp. You can submit your claims by –

  • Using the member app by taking a photo of the account and your proof of payment and submitting it in a few easy steps;
  • Emailing the photo of the account and your proof of payment to claims@medihelp.co.za; or
  • Submitting your claim by logging in to Medihelp's Member Zone and using the "Submit a claim" option – you can also submit your DRC and PPN claims on the Member Zone.

What information should be printed on accounts that I submit?

To ensure that your claim is valid (according to the Medical Schemes Act and Medihelp’s Rules), please ensure that the following details are on the printed account:

  • Your membership number
  • The member's name and surname
  • The name, surname and date of birth of the patient
  • Medihelp Medical Scheme – not "Private" (this has tax implications)
  • The amount charged per item
  • The amount you have paid
  • The relevant code(s) such as ICD-10, NAPPI and item code(s)
  • The healthcare practitioner's name and practice code number
  • The date on which the service/procedure was rendered/performed

The account should not contain any modifications made by hand, as this will cause your claim to be invalid. Please attach your proof of payment to the account.

How much time do I have to submit the claim?

Please ensure that your claim reaches us on or before the last day of the fourth calendar month after the month in which the service was rendered. If the claim is rejected because of omitted or incorrect information, you have 60 days from the date of the rejection to resubmit the amended claim.

Why is it so important to check my claims statements?

It is essential that you check your claims statements for details of your claims that have been settled, and to see which amounts were paid to healthcare providers or to you.

The message codes will indicate if additional information is required for your claim to be processed. Please remember that you only have 60 days from the date of your claims statement to submit any information we request.

Who should I contact for any claims-related enquiries?

Please send email to enquiries@medihelp.co.za, phone 086 0100 678 or check for details on your claims statements on the Member Zone.

For optometric claims and enquiries, please email info@ppn.co.za.

For dental claims, email claims@dentalrisk.com and for dental claim enquiries, email medihelp@dentalrisk.com.

What is meant by "Medihelp Tariff"?

Medihelp Tariff refers to the tariff paid by Medihelp for different medical services, and can include for example the contracted tariff for services agreed with certain groups of service providers such as hospitals, the Medihelp Dental Tariff for dental services, and the single exit price for acute medicine. The various tariffs are defined in the Rules of Medihelp and approved by Medihelp’s Board of Trustees.

Doctors and other service providers may charge tariffs that differ from the Medihelp tariff. If this happens, you’ll have to pay the difference to the service provider.

Negotiate with your doctor: Remember that, as with any other service, you may negotiate a discount with the supplier. It is advisable to determine in advance how much the service provider will charge and how much Medihelp will pay for a specific service. By doing so, you can calculate possible out-of-pocket expenses in advance in order to prevent any unexpected medical expenses.

HealthPrint

Medihelp’s free wellness programme

What is HealthPrint and who can join?

HealthPrint is Medihelp’s free online wellness programme designed to improve your health and promote your wellness. On HealthPrint, you can create and monitor your unique health profile. HealthPrint also includes a pregnancy and baby/toddler programme that is there for you during your journey as parent, a BMI weight-loss programme, and other exciting functionalities. Click here to join.

How can a member join HealthPrint?

To register for HealthPrint, simply click here (you will need your Medihelp membership number at hand). It’s quick, easy and most of all, free!

Where can I find more information about Medihelp’s running and cycling club?

Anyone is welcome to join Medihelp MultiSport, Medihelp’s club for runners and cyclists. Become part of this exclusive active community, make friends and get fit while having fun! Click here to find out more.

Terminology

Answers to common Medihelp membership questions

Amniocentesis

A prenatal test in which a small amount of amniotic fluid is removed from the sac surrounding the developing fetus to screen for abnormalities.

Arthroscopy

A minimally invasive surgical procedure on a joint to examine and/or treat damage using an arthroscope, an endoscope (flexible tube with a light and camera attached to it) inserted into the joint through a small incision.

Back treatment programme

A non-surgical treatment plan that lasts up to nine weeks and is developed per eligible individual by an interdisciplinary team based on the patient's clinical profile.

Colonoscopy

A screening test of the entire colon where an endoscope (a flexible tube with a light and camera attached to it) is used to examine and/or detect possible gut problems.

Emergency

Any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment or dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy.

Formularies

A list of preferred items (medicine, pathology, prosthetic or otherwise) based on its safety efficacy and cost-effectiveness, used in the diagnosis and/or treatment of a medical condition.

Gastroscopy

A nonsurgical procedure where an endoscope (a flexible tube with a light and camera attached to it) is used to help confirm or rule out problems of the upper part of gastrointestinal system.

Chronic care programme

An individualised programme where a case manager is appointed to support you with treatment and advice for optimising your well-being if you suffer from high blood pressure, high cholesterol and diabetes simultaneously

Hospice

A facility designed to provide support to sick or terminally ill patients and their families.

Medihelp Reference Price (MHRP)

The MHRP applies to all pre-authorised PMB medicine. Price is determined according to the most cost-effective treatment based on evidence-based principles. The MHRP differs per benefit option and is subject to change.

Medihelp Tariff (MT)

The tariff paid by Medihelp for different medical services, which can include the contracted tariff for services agreed with certain groups of service providers such as hospitals, the Medihelp Dental Tariff for dental services, and the single exit price for acute medicine.

Nuclear radiology

A medical specialty which uses radioactive substances to diagnose and treat a disease.

Protocols

A set of clinical guidelines relating to the optimal sequence of diagnostic testing and treatments for specific conditions, including clinical practice guidelines, standard treatment guidelines, disease management guidelines and formularies.

Sigmoidoscopy

A procedure where an endoscope (a flexible tube with a light and camera attached to it) is used to help confirm or rule out problems of the sigmoid colon (the final segment of the colon).

Sub-acute care

A facility used as an alternative to hospitalisation that provides post-operative care or care to patients with debilitating disease, or post-injury care.

Supplementary health services

Supporting health services including physiotherapy, speech therapy and dietician services. Benefits differ according to the different plans.

Tetanus

A life-threatening bacterial infection that produces a toxin which affects the brain and nervous system, causing painful muscle spasms and serious breathing difficulties.

BMI

Body mass index

CDL

Chronic Diseases List

COPD

Chronic obstructive pulmonary disease

CPAP

Continuous positive airway pressure

CT

Computerised tomography

DBC

Document-Based Care

DSP

Designated service provider

EMS

Emergency medical services

EVARS

Endovascular aortic replacement surgery

FOBT

Faecal occult blood test

GP

General practitioner

HIV

Human Immunodeficiency Virus

HPV

Human papilloma virus

MHRP

Medihelp Reference Price

MMHP

Maximum Medical Aid Price

MORP

Medihelp Oncology Reference Price

MRI

Magnetic resonance imaging

MT

Medihelp tariff

PET

Positron emission tomography

PMB

Prescribed minimum benefits

PPN

Preferred Provider Negotiators

TTO

To take out (medicine)

Medihelp chatbot
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