PMB & CDL
What are PMBs?
PMB (Prescribed Minimum Benefits) are a series of services and conditions that medical schemes must cover in terms of the Medical Schemes Act 131 of 1998, including:
- Medical emergencies (in term of the legal definition);
- 270 listed diagnosis and treatment pairs (DTPs); and
- The 26 diseases on the Chronic Diseases List (CDL).
What are the rules for PMB?
All PMB must be:
- Follow specialised protocols; and
- Must be rendered by designated service providers (DSPs).
Medicine formularies apply for Prime Network and Necesse members.
Please always study your benefit option member guide to ensure that you use the DSPs indicated for your option and adhere to all the rules of your option.
How do I access my PMB?
PMB treatment can include:
- Consultations and services
Consultations & services
- Register – phone Medihelp at 086 0100 678. Give the consultant the ICD-10 codes provided by your doctor to register your illness. You will receive an authorisation schedule with approved services.
- Only treatment specified on your authorisation schedule will from part of your treatment protocol and will qualify for benefits.
- Any new services that your doctor wants to prescribe must be pre-authorised through the same process.
- Go to Medihelp’s secured site for members at www.medihelp.co.za or phone the contact centre at 086 0100 678 for a PMB/chronic medicine form.
- Complete the form and submit it according to the instructions on the form.
- Include all the required verification documents for your specific condition, such as test results and doctors’ reports.
- You will receive an authorisation schedule as soon as your pre-authorisation is complete.
- Necesse and Prime Network option medicine is subject to a formulary (list of medicines for which the Scheme will pay PMB).
- PMB hospitalisation must be pre-authorised by phoning Medihelp on 086 0100 678. If you fail to do this, a 20% co-payment will apply.
- Emergency admissions must be authorised on the first working day following the admission.
- Prime Network and Necesse members must be admitted to a network hospital to avoid a 35% co-payment.
- Only services that adhere to the legal criteria for medical emergencies will qualify for PMB, provided that the doctor motivates it as such.
- Call Medihelp at 086 0100 678 to authorise the emergency. Emergencies must be authorised as soon as possible after the incident, but no later than the first working day following the emergency admission.
What is the MHRP?
The MHRP (Medihelp Reference Price) applies to all PMB medicine. Medihelp applies an average benefit amount per specific medicine according to therapeutic class and that benefit amount will be applied to all medicines that contain the same molecule in the same therapeutic class. You can download the MHRP list from Medihelp’s website at www.medihelp.co.za or phone the contact centre at 086 0100 678.
What are the legal criteria for a medical emergency?
The Act defines a medical emergency as “the sudden and unexpected onset of a health condition that requires immediate medical and/or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.”
IMPORTANT: A medical emergency must be diagnosed as such by the doctor at the emergency unit.