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

Does Medihelp offer a day surgery network?

Medihelp covers a defined and clinically appropriate list of procedures that should be performed in a day surgery 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; and
  • Dental procedures.

You can view the full list of day surgery 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. The GP network is compulsory for Prime network members and has been compiled to match 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.

 

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
  • The ICD-10 code(s)

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What is a medical aid savings account?

At the beginning of the year or when you join Medihelp, you have access to the full credit of 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 versatility 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 fall within 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 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, and can 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 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. New-borns 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 without proof of studies on all Medihelp’s plans except for the Necesse plan and for adopted/foster children where child dependant rates apply until 21 years.

 

How do I register my dependants?

Use one of the following ways:

  • Log in to Medihelp’s Member Zone and download the registration form.
  • Download the registration form on Medihelp’s website
  • Call Medihelp’s Customer Care centre on 086 0100 678.
  • Send email to NewBusiness@medihelp.co.za.

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.
  • 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 monthly breakdown of the 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 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 app for members.
  • Log in to Medihelp’s Member Zone. On the home page, click on “My Profile” and then “Personal information”.
  • 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
  • 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 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?

  • 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
  • Dependant code(s)
  • 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 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

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

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. 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:

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 and Necesse Network 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 surgery network.
  • 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 prescribed minimum benefits (PMB) registration/pre-authorisation form
  • ICD-10 code
  • Procedure code(s)

More information

  • Prescribed minimum benefits (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
  • 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

    • Membership number
    • Item and procedure codes
    • 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.

    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 prescribed minimum benefits (PMB) chronic medicine


    Required information

    • Membership number
    • Details of patient
    • Completed forms

    More information

    Non-prescribed minimum benefits (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

    Prescribed minimum benefits (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 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 prescribed minimum benefits (PMB) chronic medicine only.

    Required information

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

    Important:

    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
    • Fax: 012 336 9540

    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 for prescribed minimum benefits (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 that is not administered during hospitalisation must be pre-authorised. If not, a 20% co-payment will apply.

    Oncology

    Cancer treatment programme (in cooperation with the oncologists of the Independent Clinical Oncology Network (ICON))


    Prime network options

    Designated service provider (DSP) 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:
      • within the Independent Clinical Oncology Network (ICON), and
      • according to the ICON treatment protocol
    • Please note: A co-payment will apply should you deviate from the protocol for non-PMB services, and no benefits will be granted should you deviate from protocols for PMB services.
    • 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: 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

    • 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 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, 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?

    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 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; or
    • 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 of Dental Risk Company (DRC) and Preferred Provider Negotiators (PPN) claims on 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 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. 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. Optometric services on Prime 1 are for the member’s own account..

    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

    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 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/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

    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.

    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’s benefits are indicated as core benefits, added insured benefits and day-to-day benefits. Day-to-day benefits are mostly out of hospital, non-emergency benefits like GP and specialist consultation, radiology and pathology (out of hospital), dental, optometry, acute and self-medication. Day-to-day benefits mostly have annual limit or if your option has a savings account these benefits will pay for day-to-day services.

    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.

    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.

    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 medicine not prescribed, namely

    • PMB/chronic medicine (pre-authorisation and designated service providers (DSP) may apply to PMB/chronic medicine) – medicine must be prescribed by a doctor/specialist for three and more months
    • Non-PMB chronic medicine – medicine must be prescribed by a doctor/specialist for three and more months
    • Acute medicine – medicine prescribed by a doctor
    • Self-medication – over the counter medicine
    • Medicine to take home after discharge from hospital (to-take-out medicine (TTO)).

    Note: Medihelp has a preferred pharmacy network and all our members will benefit from using the network (Necesse members have to obtain their medicine within the network).

    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)

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