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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 tariff agreements. This is a more affordable option, since network doctors' 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 general practitioner (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.)

Members of the Medihelp non-network plans must use the preferred providers appointed by Medihelp for certain services and procedures to avoid co-payments, such as specialists in the Medihelp specialist networks and day surgeries in the Medihelp day procedure facilities in the Medihelp day procedure network(read more below).

Does Medihelp offer a day procedure network?

Medihelp covers a defined and clinically appropriate list of procedures that should be performed in a day procedure facility for all medical aid plans. Please ensure that you use a facility in this network when undergoing any of the following procedures, to avoid a 35% co-payment:

  • Ophthalmological procedures;
  • Ear, nose and throat procedures;
  • Endoscopic procedures;
  • Removal of skin lesions;
  • Circumcisions;
  • Dental procedures; and
  • Other procedures as pre-authorised.

You can view the full list of day procedure facilities in the network here .

Does Medihelp have a network of GPs?

Medihelp has partnered with a quality network of GPs who charge a negotiated Medihelp rate so that members need not pay additional fees when consulting them. Using the GP will benefit members of all options, but it is compulsory for Prime network members to have a network GP refer them to a specialist. The network was matched to the GPs currently used by Medihelp members countrywide, to ensure ease of access. Search for a network GP in your area.

Members of Necesse also benefit from a dedicated Necesse GP network. They should consult a GP in this network to avoid co-payments. Search for a Necesse network GP in your area.

Members of the Prime network options and Necesse must remember to obtain a specialist referral from their network GP.

Do I need a referral to a specialist to prevent co-payments?

Members of the Prime network plans must be referred to a specialist by a network GP to prevent a 35% co-payment on the specialist’s account. Your network GP can submit the request for a specialist referral on your behalf or you can submit the request on the Member Zone.

What do I need to request a referral online?

Please obtain the following information from your network GP to request a specialist referral online:

  • The membership number, name and surname of the member and the patient
  • The referring network GP’s practice number
  • The practice number of the specialist to whom the patient is referred and the date of the appointment
  • The ICD-10 code(s)

    •  

What is a medical savings account?

At the beginning of the year or when you join Medihelp, you have access to the full amount in your medical savings account, which is available separate from your day-to-day benefit pool. The funds in this account earn interest during the year. Any unused funds which accumulate are carried over to the next year. If you leave the Scheme before the end of the year or choose to change to a plan without a savings account, we will calculate how much of the savings you have used and how much you have already contributed to the account. If you have used more than you have contributed, you will need to refund the difference to Medihelp. If you are on Medihelp’s Prime 3, Elite, Prime 2 or Unify plans, a medical savings account will form part of your benefits.

Which Medihelp plans offer a savings account?

The Prime 2 and Unify medical aid plans both include a savings account in addition to other insured benefits. From 2021, Medihelp’s Prime 3 and Elite medical aid plans also offer a 10% savings account together with richly insured cover for day-to-day medical expenses, allowing for greater flexibility and less out-of-pocket expenses. You can use these funds to pay for GP and specialist services, standard radiology and pathology, acute and over-the-counter medicine, non-PMB chronic medicines and supplementary health services, including physiotherapy.

Does Medihelp have a medical aid plan for students?

Yes: The Necesse Student plan is an affordable medical aid plan for full-time students. You get quality cover at private hospitals, GPs and other healthcare facilities that are part off the Necesse network. This plan 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 113 quality private network hospitals as an alternative.

What does added insured benefits mean?

Added insured benefits offer enhanced medical cover and are available on all Medihelp medical aid plans. These benefits include flu vaccines, maternity and baby benefits, screenings, preventive and wellness services. Some of these benefits will only be activated by registering on HealthPrint, Medihelp’s free online health and wellness platform.

Membership

Answers to common Medihelp membership questions

Underwriting conditions


What are late-joiner penalties?

Late-joiner penalties apply if beneficiaries who have never been members of a medical scheme before, enrol for the first time, or if there were prolonged breaks in coverage at previous medical schemes.

How do I find out more about late joiner penalties?

Phone 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. Medihelp may apply a general waiting period or a condition-specific waiting period.

  • A general waiting period of up to three months applies 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 applies from the date that you joined. During this time, you will not be entitled to benefits for a particular condition for which you receive, medical advice, a 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 may I register on my medical aid?

You may register any of the following as your dependants at Medihelp if you are responsible for their family care and support:

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

When will they become active members?

Your spouse, children, grandchildren, adopted or foster children, can become active new dependants on your medical aid immediately. New-borns must be registered within 90 days of their birth.

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

Did you know? On Medihelp’s Prime range you pay only for two children younger than 18 years; the rest receive free medical aid cover. You also 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 on all Medihelp’s plans except for the Necesse plan, where the cut-off age is 21. In terms of legislation, adopted and foster children may be registered as child dependants until they are 21 years old.

 

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 principal member.

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, phone 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 the next year.
  • The value of claims not paid by the Scheme and its partners (DRC and PPN) during the tax year.
  • The total interest you’ve earned on any positive balance in your medical savings account (applicable to the Prime 3 , Elite , Prime 2 and Unify plans).
  • A breakdown of the Monthly contributions paid for the principal member and all active dependants.

    •  

    You can download your tax certificate and a tax reconciliation on the Member Zone.

     

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 may not unfortunately 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 app for members.
  • Log in to Medihelp’s Member Zone . On the home page, click on “My Profile” and then “Personal information”.
  • Phone 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
  • Mobile 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 are Medihelp’s banking details?

Medihelp Medical Scheme
Bank: ABSA
Branch: Arcadia
Account type: Cheque
Account number: 61 00 000 88
Branch code: 632005
Reference: 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?

  • As soon as you become a Medihelp member, we post your membership card to your preferred address.
  • You can also view and/or download your membership card by logging in to Medihelp’s Member Zone and selecting “Membership” and then “Membership card” on the homepage.
  • With Medihelp’s member app, you always have access to your membership card – and you can quickly share it electronically when needed.

What information is featured on my membership card?

Your card contains the following details:

  • Name of the member
  • Your unique membership number
  • ID number
  • Benefit option
  • Dependants' code
  • Enrolment date (date when your membership was activated)
  • Date when the card was issued
  • Date when you qualify for benefits
  • Details of registered dependants (if applicable)

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. You can also request a new card 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

Log in to Medihelp’s Member Zone  and select “Pre-auths” on the menu bar. Select the type of pre-authorisation in the dropdown menu (e.g. hospitalisation). Follow the prompts on the next page to submit your request.

Medihelp app for members

The app is available on iStore and Google PlayStore.

Contact us

Phone Medihelp’s pre-authorisation department on 086 0200 678 to apply for pre-authorisation, or send an email to the relevant department .

 

All hospital admissions

All hospital admissions must be pre-authorised, and emergency admissions must be authorised on the first workday after the admission. All Medihelp members must use the Medihelp day procedure network for ophthalmological, endoscopic, ear, nose and throat procedures, removal of skin lesions, dental procedures and circumcisions. Members of Prime 1, 2, 3 and Necesse must use for all procedures that are not performed in the day procedure network.

Phone Medihelp on 086 0200 678 to get authorisation for your admission to a State or private hospital, day clinic as well as psychiatric facility. To request approval for dentistry performed in hospital, email 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:

Information you need to pre-authorise

  • Your membership number and details
  • Details of the patient
  • Procedure and diagnosis codes (get these from your treating doctor)
  • Treating doctor’s details and practice number
  • Details of the hospital to which the patient will be admitted, and the practice number
  • Date and time of admission

Additional information may be required for certain procedures, such as medical reports, X-rays or blood test results.

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 network and Necesse options
  • Use the day surgery network for ophthalmological, endoscopic, dental, ear, nose and throat procedures, removal of skin lesions and circumcisions to avoid a 35% co-payment. View the day procedure network .
  • Standard co-payments apply to certain procedures (please refer to your 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, and
    • facility

More information

  • Authorisation will be considered only if the services are 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 are not considered for frail care services.

Prescribed minimum benefits (PMB)


Required information

  • Membership number
  • Details of patient
  • Completed prescribed minimum benefits (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 by phoning 086 0100 678
  • Emergency admissions must be authorised on the first workday following the admission

Specialised dentistry

  • Dental procedures performed in hospital under anaesthesia
  • Dental procedures performed 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, and
    • anaesthetist.

More information

DRC must also pre-authorise hospital admissions for extensive dental treatment performed under general anaesthesia or the removal of impacted teeth. Co-payments will apply if you do not obtain pre-authorisation.

Emergency transport services


Netcare 911

Tel: 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 PMB/chronic medicine application form

PMB chronic medicine

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

Always apply for pre-authorisation before obtaining your chronic/PMB chronic medicine.

If you plan on traveling abroad, please inform Medihelp before your departure.

Specialised radiology

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

  • Tel: 086 0200 678

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 MRI and CT imaging, as well as PET imaging (for members of the Plus option), must be pre-authorised. If not, these scans will be excluded from benefits, except if the service qualifies for PMB.
  • Angiography does not require pre-authorisation.

Oxygen

Not during hospitalisation


Required information

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

More information

Oxygen administered while not in hospital must be pre-authorised. If not, a 20% co-payment will apply.

Oncology

Medihelp offers a cancer treatment programme (in cooperation with the oncologists of the Independent Clinical Oncology Network (ICON))


Prime network options

Designated service providers(DSPs) for oncology medicine:

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 -
    • from ICON oncologists,
    • according to the ICON treatment protocol
  • Please note:Oncology received outside ICON and that deviates from ICON protocols will attract co-payments./li>
  • 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

If you or any of your dependants plan to travel abroad, please inform Medihelp of your departure date, length of stay abroad and the country or countries you plan to visit before you leave. In this way, we can advise you on the process you should follow to ensure that any claims for possible medical services rendered abroad are processed effectively.

Please note: Necesse members do not have cover for medical treatment obtained abroad.


Required information

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

More information

  • Benefits are paid according to the applicable tariff payable for a similar service in South Africa
  • Members receive 90 days’ emergency cover
  • PMB are 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 must use on their accounts to inform medical schemes about the conditions for which their members received treatment, so that claims can be settled correctly. Always have the ICD-10 code available when applying for pre-authorisation or referrals.

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 to manufacture generic medicine,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, which will be paid at 100% of the Maximum Medical Aid Price.
  • Use only authorised PMB medicine, as this will be paid at 100% of the Medihelp Reference Price.

What information 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?

As soon as we’ve processed a claim, you will receive an interim claims statement notifying you of all claims processed for payment. After each payment run, you will receive a detailed claims statement containing all the information related to the claim(s), and indicating any payments and/or rejections.

You can also phone our Customer Care centre on 086 0100 678, or log in to Medihelp’s  Member Zone and search under “Claims” on the homepage to view the status of your claims.

How do I submit a medical aid claim?

Use one of these options:

  • Use the member app by taking a photo of the account and your proof of payment and submitting it in a few easy steps;
  • Email the photo of the account and your proof of payment to claims@medihelp.co.za.
  • Submit your claim by logging in to Medihelp's Member Zone and using the "Submit a claim" option – you can also submit your dental and optometry claims to Dental Risk Company (DRC) and Preferred Provider Negotiators (PPN) via the Member Zone.

What information should be included when submitting a claim?

To ensure that your claim is valid according to the Medical Schemes Act and Medihelp’s Rules, please ensure that the following details appear on the 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 healthcare practitioner’s name and practice code number
  • The amount charged per item
  • The amount you have paid
  • Your proof of payment (attached)
  • The relevant codes such as ICD-10, NAPPI and item code(s)
  • 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. The claim must also be in a valid format – we do not accept claims in Word or Excel format.

How much time do I have to submit a claim?

Make sure that your claims reach us on or before the last workday 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 rejection to resubmit the amended account.

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 in case of any claims-related enquiries?

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

In case of optometry claims and enquiries, please email info@ppn.co.za . Members of Prime 2 and Unify must send their accounts to claims@medihelp.co.za, and enquiries can be directed to enquiries@medihelp.co.za. Optometry services on Prime 1 are for the member’s own account..

To submit dentistry claims, email claims@dentalrisk.com to enquire about a dentistry claim, email medihelp@dentalrisk.com .

What is meant by Medihelp tariff?

Medihelp tariff refers to the tariff paid by Medihelp for 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

HealthPrint is a free online health and wellness platform designed to improve your health and promote your wellness. Any member of Medihelp may join HealthPrint and activate rich additional benefits that enhance their medical aid cover, such as insured maternity benefits and the Early Detection programme to support members with certain undiagnosed chronic conditions. HealthPrint also includes the Maternity and Baby programme that support you on your journey as a parent, the Healthy Weight programme, Medihelp MultiSport for runners and cyclists as well as a host of other benefits.

How can a member join HealthPrint?

To register for HealthPrint, simply click here (you will need your Medihelp membership number). 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/walkers residing in and around Gauteng North and cyclists nationwide. Become part of this exclusive community, make friends and get fit while having fun! Click here to find out more.

Terminology

Answers to common Medihelp membership questions

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

he back treatment programme provided by Document Based Care (DBC) is a non-surgical intervention in lieu of surgery for the management of spinal column disease/conditions/abnormalities. This approach to the treatment of back and neck pain involves an interdisciplinary team handling the rehabilitation programme, which is individualised for each patient based on the patient’s needs and clinical diagnosis. Patients are assessed to ascertain if they are eligible to participate in the programme. The back treatment programme is also a prerequisite for spinal column surgery.

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

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.

Day-to-day benefits

Medihelp pays day-to-day benefits for services rendered mostly out of hospital that do not relate to an emergency, for example GP and specialist consultations, radiology and pathology (out of hospital), dentistry, optometry, acute and self-medication. Day-to-day benefits will usually have an annual limit. If your option has a savings account, these services will be paid from the available funds in your savings account.

Early Detection programme

A programme developed specifically to identify beneficiaries with undiagnosed cases of high blood pressure, diabetes and high cholesterol to support and help them manage their conditions.

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.

Formulary

A list of preferred items (medicine, pathology, prosthetic or otherwise) compiled on the basis of the safety, efficacy and cost-effectiveness thereof, to be 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.

Hospice

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

Medicine

Medihelp distinguishes between five types of medicine prescribed by a doctor, dentist or specialist or obtained without a prescription, namely:

  • PMB chronic medicine is medicine prescribed by a doctor/specialist for three months’ use or longer as treatment for a registered PMB condition. Pre-authorisation and designated service providers (DSPs) may apply to PMB chronic medicine.
  • Non-PMB chronic medicine is medicine prescribed by a doctor/specialist for three months’ use or longer as treatment for a registered non-PMB chronic condition.
  • Acute medicine is medicine prescribed by a doctor for use not exceeding two months.
  • Self-medication is medicine you can buy over the counter without a prescription.
  • TTO (to take out) medicine is medicine prescribed to take home after discharge from hospital.

Medihelp has a preferred pharmacy network and all our members will benefit from using the network. Necesse members have to obtain their medicine from network pharmacies in order to qualify for benefits.

Medihelp Reference Price (MHRP)

The MHRP applies to all pre-authorised PMB medicine. The MHRP 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 facility

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

Supplementary health services

Supporting health services including physiotherapy, speech therapy and dietician services. Benefits for these services 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)