Hospitalisation and networks

How do hospital benefits work?

• Medihelp pays benefits for hospitalisation at 100% of the Medihelp tariff (the tariff contracted with hospitals for services).
• Your cover for hospitalisation has no overall annual limit.
• You may be responsible for procedure-specific co-payments on certain non-PMB procedures.
• Sub-limits or maximum benefits for services and products such as prostheses as determined by your benefit option, will still apply.
• All non-emergency hospital admissions have must pre-authorised. If you don’t pre-authorise an admission, you will be responsible for a 20% co-payment on your hospital account.
• All emergency admissions must be authorised on the first work day after the admission.
• Emergency admissions are subject to the definition of emergencies as specified in the Medical Schemes Act.
• All network option members who voluntarily use non-network hospitals will be responsible for a 35% co-payment.
• A 35% co-payment will apply if members of the network plans voluntarily make use of a non-network day procedure facility and if members of non-network plans don’t use a day procedure facility for the following procedures: all ophthalmological, endoscopic and ear, nose and throat procedures, skin lesion removal, dental procedures, circumcisions and procedures as pre-authorised. Members of MedMove! who voluntarily make use of a non-network day procedure facility for all day procedures will have a co-payment of R11 250.

What information do I need to pre-authorise hospitalisation?

• Your membership number
• The details of the patient
• The procedure and diagnosis codes as provided by your doctor
• The doctor’s details and practice number
• The details and practice number of the hospital you will be admitted to
• The date and time of the planned admission
• The details of the anaesthetist if you are having a dental procedure

REMEMBER: Some procedures will only be pre-authorised after you have submitted additional information such as test results and X-rays. This means you must phone well in advance to pre-authorise a planned procedure. Medihelp’s pre-authorisation consultants will advise you on what you will need when you contact us for pre-authorisation.

How do I pre-authorise hospitalisation?

• You can use Medihelp’s smartphone app for members.
• Log in to Medihelp’s Member Zone and and select “Pre-auths”.
• Email all the required detail to hospitalauth@medihelp.co.za.
• Phone Medihelp’s pre-authorisation consultants on 086 0200 678.
• In the case of dental procedures, you can phone Dental Risk Company (DRC) at 087 943 9618 or send an email auth@dentalrisk.co.za.   

How do I get authorisation for dental procedures that must be performed in hospital?

Dental Risk Company (DRC) manages Medihelp’s dental benefits and you can phone them directly on 087 943 9618 or email auth@dentalrisk.co.za to pre-authorise hospital admissions for dental procedures. The DRC consultant will also be able to tell you whether your benefit option covers the treatment. All members of non-network options must use day procedure facilities for dental procedures and all members of network options must use a day procedure facility in the network to avoid a 35% co-payment. MedMove! members must use a day procedure facility in the network to avoid a R11 250 co-payment.

The DRC consultant will need the following information:

• Your membership number
• The details of the patient
• The procedure and diagnosis codes as provided by your dentist
• The treating dentist’s details and practice number
• The details and practice number of the hospital/day clinic where you will be admitted
• The date and time of admission
• Details of the anaesthetist