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Pre-authorisation and claims

What is pre‑authorisation?

Pre-authorisation is approval from the medical aid before you undergo certain treatments or procedures, or are admitted to hospital. It allows Medihelp to confirm that the planned treatment is appropriate for your condition and covered by your plan.

How do I submit a claim?

Use one of these options (please remember to include your proof of payment, if applicable):

How do I know whether a claim was paid?

You can check whether a claim has been paid on your claims statement, on the Member Zone under Claims, or by calling Client Care on 086 0100 678.

Once we’ve processed a claim, we’ll email you an interim claims statement. We also send a detailed statement twice a month, covering all claims, payments, and rejections.

What should be on my claim?

For your claim to be valid, the account must include:

  • 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
  • The amount charged per item
  • The amount you paid
  • Your proof of payment (attached)
  • The relevant codes, such as ICD-10, NAPPI, and item code(s)
  • The date the service was rendered

Please note that any handwritten changes to the account will make your claim invalid.

How much time do I have to submit a claim?

You must submit your claim by the last workday of the fourth calendar month after the service was rendered. If your claim is rejected due to missing or incorrect information, you have 60 days from the date of rejection to resubmit.

What should I do if my claim is rejected?

Review the reason for rejection, correct any errors, and resubmit the claim, or contact Medihelp for assistance.

Can I submit claims on the app?

Yes, you can submit and track all your claims on the Member Zone or Medihelp app.

How do I get hospital authorisation?

Easily pre-authorise your hospital admission on the Medihelp Member Zone

  • Select Pre-auths on the menu bar.
  • Select the type of pre-authorisation from the dropdown menu (for example, hospitalisation).
  • Follow the prompts and submit.

Information you need for pre-authorisation

  • 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 and the practice number of the admitting hospital
  • 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

  • All hospital admissions must be pre-authorised ­– authorise well in advance.
  • If not pre-authorised, you will pay 20% of what the scheme would have covered.
  • Emergency admissions must be registered on the first workday after admission.
  • If you’re on a network plan, voluntary (non-emergency or planned) admission to a non-network hospital will result in a co-payment. View our network facilities here.
  • Standard co-payments apply to certain procedures (refer to your member guide).

What happens if I don’t get authorisation?

Without pre-authorisation, your claim may be partially paid or declined, leaving you responsible for the costs.

How do I know if a procedure is covered?

You can check your plan benefits on the Member Zone, contact Client Care to confirm available benefits, or request pre‑authorisation to confirm whether a procedure is covered.