Why do I need to get Pre-Authorisation?
When do I need Pre-Authorisation?
The Scheme has specified treatments that require pre-authorisation. Members are encouraged to review their plans before visiting their doctors to ensure that the treatment does or does not require Pre-authorisation.
If in doubt, please email: authorisations@sizwehosmed.co.za or Call: 086 010 1176 to confirm.
Do I need Pre-Authorisation for hospital admission?
Yes, you need pre-authorisation before hospital admission. Please adhere to the following guidelines:
- 72 hours before a planned procedure
- Within 48 hours of an emergency procedure.
What happens if I don’t get a Pre-Authorisation?
Failure to get pre-authorisation may result in co-payment or claim rejection.
What information do I need to get Pre-Authorisation
The following information is required for pre-authorisations:
- Main member’s membership number
- Patient/dependant code, name, and ID number
- Date of birth
- Doctor’s practice number
- Anaesthetist’s practice number
- Hospital name and practice number
- Date and duration of the admission
- Procedure codes
- ICD10 codes
How do I submit a Pre-Authorisation?
You can submit a Pre-authorisation request using the following contacts:
Email: authorisations@sizwehosmed.co.za
Call: 086 010 1176
Can I visit a Specialist without a referral?
Some Sizwe Hosmed plans require a GP referral before treatment by a specialist. Members are encouraged to review their plans before visiting a specialist.
In which instances can I visit a Specialist without a GP referral?
You do not need a referral:
- For follow-up visits for the same ongoing condition treatment.
- Emergency treatments.
- Visits to Gynaecologists.
- Paediatrician visits for children under 24 months of age.
Where can I get further assistance on a Specialist referral?
By contacting the Scheme on the following contacts:
Email: primary.referrals@sizwehosmed.co.za
Telephone: 0860 100 87
How do I access chronic medication?
If you have a chronic condition, your treating doctor must register you for the Scheme’s Disease Risk Management Programme (DRM), designed to assist members with chronic diseases in effectively managing their conditions. Then follow these steps:
- Submit the application form, applicable test results and the chronic script to chronic@sizwehosmed.co.za.
- The medication script must have the ICD-10 diagnosis code.
- A new script is required every 6 months.
- Registration for the medication will not be backdated.
- Medication is paid at Scheme rates.
- The Scheme has a Medicine List (Formulary) and uses it as a guideline to pay or fund medication scripts that are not on the list/formulary.
How do I claim from the Scheme?
When you submit your claim, ensure that it has the following information:
- Healthcare provider’s name and practice number.
- Principal (main) member’s name and initials.
- Principal member’s medical aid number.
- Treatment date.
- Patient’s name (as per membership card). If the patient is not the main member, please list their date of birth and ID number.
- Amount charged.
- Tariff code (filled in by a doctor or specialist).
- Diagnosis made by the doctor or specialist (ICD10 code).
What are the common reasons for rejected claims?
- The required documentation was incomplete or inaccurate.
- The claim was filed after the submission deadline.
- The service provider was not part of the approved network.
- Specialist costs or the Scheme did not authorise tariffs.
- The Scheme does not cover the treatment or procedure.
- The treatment was not pre-authorised.
- The benefits exceeded.
- Duplicate claim.
- Benefits are finished.
What is partial claim payment?
This is where the Scheme pays a portion of the claim, and the member pays a portion.
What are the reasons for partial payments of claims?
If specific treatments or services are beyond the benefit limit or beyond what was authorised by the Scheme, or if additional procedures are undertaken that fall outside the member’s plan.
How do I avoid partial payment of my claim or a claim rejection?
- Always review your plan details to confirm benefits before treatments or procedures to ensure smooth processing.
- Gather and submit the required documents promptly.
- Consult with your service provider to ensure they are on the Scheme’s approved network and their fees are within the Scheme’s tariffs.
- Submit your claim within four months (120 days) of the treatment.
- Get a referral before visiting a specialist.
- Ensure your treatment is pre-authorised.
- Ensure that additional treatments suggested by your doctor fall within what was pre-authorised by the Scheme.
What is a co-payment?
This is the part of the account that a member might have to pay out of their pocket, where benefits do not cover the treatment or medication received.
What are benefit exclusions?
Benefit exclusions are specific treatments, procedures, or conditions not covered by the Scheme, such as cosmetic procedures. These exclusions are implemented to manage risk, keep premiums affordable, and ensure the Scheme’s sustainability. By being aware of what the Scheme will not pay for, members can make informed healthcare decisions and avoid unexpected out-of-pocket costs.
Please refer to the Member Guide for the list of exclusions.
What is a PMB?
Prescribed Minimum Benefits (PMBS) are defined healthcare services that all medical schemes in South Africa are legally required to cover, regardless of the plan you choose. These benefits ensure that members have access to essential diagnosis, treatment, and care for a list of specified medical conditions, including emergency medical conditions, a set of 270 defined severe conditions, and 26 chronic diseases.
PMBs aim to guarantee that no one is left without critical care when needed most, protecting your right to healthcare and reducing financial burden in serious health situations.
Is using a broker the only way to join Sizwe Hosmed?
No. One can apply directly to the scheme or opt to use the services of a broker (intermediary).
How do I select an appropriate medical scheme?
Ensure that the scheme is duly registered in terms of the Medical Schemes Act 131 of 1998. Only entities registered by the Council of Medical Schemes (CMS) can operate a medical scheme. All registered schemes’ names, addresses, and telephone numbers are published on the CMS website, http://www.medicalschemes.com/MedicalSchemes.aspx.
If you use a broker (intermediary), ensure that the CMS has accredited him/her. To ensure the broker has been accredited, prospective members should insist that brokers produce proof of accreditation with the Council and/or verify the broker accreditation status on: http://www.medicalschemes.com/AccreditedBrokers.aspx.
How do I know which benefit plan to select?
Ensure you understand how the benefit options work and select according to your healthcare needs and what you can afford. Every benefit option must include the prescribed minimum benefits (PMBs). Click here for plans.
Is membership of a medical scheme available to anyone?
The open enrolment principle means that anyone can join any medical scheme. The only exception is restricted medical schemes, where you can only join if you meet the eligibility criteria. Eligibility criteria are based on the grounds provided in the Act, which includes employment or membership of a particular employer, profession, trade, industry, calling, association or a union which has established a scheme exclusively for its employees or members.
Can I belong to more than one medical scheme at a time?
No. It is illegal to belong to multiple medical schemes at the same time. Section 28(a) of the Medical Schemes Act does not allow this. Members must ensure that their membership in a former medical scheme is cancelled before joining a new one.
Can a child become a member of a medical scheme?
Yes, as a dependant of their parents or legal guardian, provided that the relevant contributions are paid by the parents/guardian. Where the child pays for their contributions, they are registered as principal members, not as child dependants.
Is a medical scheme allowed to refuse to admit a dependant?
No. A medical scheme may not refuse admission of a member’s dependant if such a dependant meets the eligibility criteria stated in the registered rules of the scheme.
Are dependants covered if the main member dies?
Yes, without any break in membership, provided contributions are paid. It is important to inform the Scheme if one chooses not to continue. Such members are called continuation members, and one of the dependants (usually the surviving spouse) will become the principal member.
If the deceased member belonged to a restricted medical scheme, no additional dependants will be allowed on the scheme, as the link between the scheme and the person who met the eligibility criteria has been broken. For example, if the principal member dies and his wife becomes the main member, she cannot add her new husband as a dependant, and they will have to join an open medical scheme.
Do I have to give notice if I want to end or terminate my membership?
Yes, Sizwe Hosmed requires a one-month calendar notice period to terminate membership. However, contributions must still be paid until the last effective date of membership.
Do I still receive benefits if I am serving notice of termination?
Yes, until the last day of your membership, provided contributions are being paid.
Am I still liable for contributions if I request immediate termination?
Yes. A member remains liable for full contributions for the whole notice period, regardless of whether they serve the termination notice. The Scheme may institute legal proceedings to recover outstanding contributions or backdate the termination to the last date of contributions received.
Is my scheme entitled to suspend or cancel my membership when my employer fails to pay membership fees?
Yes, a member must ensure that their employer pays the correct contributions to the Scheme.
May I receive a no-claim bonus or rebate if I do not claim?
No. The Act does not allow the payment of dividends, bonuses, rebates or refunding of any portion of contributions. Benefits may also not be carried over to the next financial year. On the other hand, savings accounts are carried over to the next year and paid out to members when they leave the medical scheme and join another scheme without a savings option.
Can my scheme terminate or suspend my membership?
Yes. If you do not pay membership fees on time or have other debts owing to the scheme, submit fraudulent claims, commit other dishonest acts, or do not submit all information about your health history when applying for membership,
What happens if my membership is cancelled due to the non-disclosure of material information?
Application forms must be completed entirely and honestly. It is essential to provide honest details of pre-existing health conditions so that the Scheme can assess your risk. If unsure, ask your broker or the medical scheme to assist you.
If my membership has been terminated due to non-disclosure, can I reapply to the same medical scheme and provide the correct details?
Yes, under the open enrolment principle, a member may join any open medical scheme of their choice.
What is a designated service provider (DSP)?
A healthcare provider or group of providers that the Scheme has chosen to provide specific medical care.
What is the Scheme Tariff?
The rate at which the Scheme pays for health services to service providers on behalf of members. It is based on the National Reference Price List published by the Department of Health.
Must my employer subsidise my contributions to the medical scheme?
No, subsidies are conditions of employment, and the Act does not address such conditions.
