Network Option
Hospitalisation Benefits
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Benefits will be allocated pro rata for beneficiaries or members joining during the year.
You must obtain authorisation for any non-emergency hospital admission and related treatment by calling 0800 765 432.
If you do not obtain authorisation at least two days before any non-emergency hospital admission or related treatment, penalties may be applied and benefits may be withheld.
- YOUR MAJOR MEDICAL EXPENSES BENEFIT
Your major medical expenses benefit consists out of three categories:
Procedures performed in hospital Certain procedures performed in doctors'rooms, hospital medical facilities or day clinics, but paid from your major medical expenses benefit Additional procedures that are not performed in or out of hospital, but paid from your major medical expenses benefit. - SPECIFIED TIME LIMITS FOR PRE-AUTHORISATION
- DESIGNATED SERVICE PROVIDERS (DSPs) - NETWORK SPECIALIST
- HOW TO OBTAIN HOSPITAL PRE-AUTHORISATION
IN-HOSPITAL BENEFITS
| Benefits | Description | |
|---|---|---|
| Ambulance services - Netcare 911 - 082 911 | 100% of the agreed tariff. Subject to authorisation by Netcare 911 within 72 hours of the transport occurring. Unauthorised use of an ambulance for non-emergency treatment will not be covered by the Fund. For authorisation please call 082 911 | 100% of the agreed tariff |
| Hospitalisation - private, provincial or State hospitals |
100% of the agreed tariff for authorised admissions, if referred by a network provider Authorisation: 0800 765 432 |
100% of the agreed tariff |
| Ward accommodation |
Paid at general ward tariffs, subject to pre-authorisation Authorisation: 0800 765 432 |
|
| Take-home medication (after discharge from hospital) |
Limited to 7 days |
|
| GPs - including surgery, procedures and consultations |
100% of the agreed tariff for authorised admissions, if referred by a network GP Authorisation: 0800 765 432 |
100% of the agreed tariff |
| Specialists - including surgery, procedures and consultations |
100% of the agreed tariff for authorised admissions, if referred by a network specialist Call 0800 765 432 for specialist referral and authorisation |
100% of the agreed tariff |
| Radiology - including MRIs, CT scans and radio-isotope studies |
100% of the Agreed Tariff if requested by a DSP specialist on referral by a DSP GP An upfront co-payment of 25% of cost to a maximum of R2 680 per Beneficiary per annum is payable by the Member on all MRI and CT scans. Subject to pre-authorisation, clinical motivation and Managed Care Protocols Authorisation: 0800 765 432 |
100% of the agreed tariff |
| Pathology | 100% of the agreed tariff if requested by a network specialist on referral by a network GP | 100% of the agreed tariff |
| Organ transplants |
Subject to pre-authorisation and PMBs Where the recipient is a beneficiary of the Fund, services rendered to the donor and the transportation of the organ are included in this benefit Where the donor is a beneficiary of the Fund, but the recipient is not, the donor costs will not be covered by the Fund, since these costs should be covered by the recipient's medical scheme |
|
| Hospitalisation, organ and patient preparation | 100% of the agreed tariff | 100% of the agreed tariff |
| Immuno-suppressant drugs dispensed in hospital or dispensed by the hospital to take out for use after discharge | 100% of cost | |
| Subsequent supplies of immunosuppressant drugs | 100% of cost, subject to pre-authorisation | |
| Robotic-assisted laparoscopic prostatectomy | No benefit | |
| Blood transfusions, transportation of blood and blood products | 100% of the agreed tariff at approved network providers | 100% of the agreed tariff |
|
Auxiliary services in hospital:
|
100% of the agreed tariff for authorised admissions at network providers The service/procedure must be directly related to the authorised admission |
100% of the agreed tariff |
| Psychiatric treatment in hospital or at a registered facility |
Prescribed minimum benefits (PMBs) only Subject to pre-authorisation and limited to 21 days per beneficiary per year Authorisation: 0800 765 432 |
|
| Maxillofacial treatment |
100% of the agreed tariff, subject to pre-authorisation Only covers facial trauma and removal of impacted wisdom teeth |
100% of the agreed tariff |
IN-DOCTORS' ROOMS, HOSPITAL MEDICAL FACILITIES OR DAY CLINICS
| Benefits | Description | |
|---|---|---|
| Certain procedures performed in doctors' rooms only | 100% of the agreed tariff if performed at network GPs and limited to the DSP list of procedure codes | 100% of the agreed tariff |
| Hospitalisation is subject to approval of clinical motivation and managed care protocols |
Authorisation: 0800 765 432 |
|
| Oncology, radiotherapy and chemotherapy in and out of hospital - medication/chemicals, related radiology, including MRIs and CT scans and pathology |
Limited to Statutory Prescribed Minimum Benefits only. Full clinical motivation and treatment plan is required by the treating specialist and assessment against the SAOC appropriate tier guidelines as applied by the Fund, for clinical appropriateness. Subject to pre-authorisation, registration on the Oncology Programme and oncology management protocols Registration: 0800 118 666 |
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|
Endoscopic examinations:
|
100% of the agreed tariff, subject to pre-authorisation and clinical motivation by a network provider R2 680 co-payment applies if performed in hospital without an approved clinical indication and Fund approval Anaesthetic costs related to these scopes are limited to local or regional anaesthetic General anaesthetic costs are not covered Pathology costs related to these procedures will be covered from major medical expenses Call 0800 765 432 to obtain pre-authorisation |
100% of the agreed tariff |
|
Refractive surgery and examinations performed by an ophthalmologist, including:
|
No benefit | |
| Basic dentistry procedures in hospital - removal of teeth and multiple fillings for children 7 years and younger | No benefit | |
| Specialised dentistry procedures in and out of hospital - dental implants and removal of impacted wisdom teeth | No benefit Removal of impacted wisdom teeth covered under maxillofacial benefit |
|
| Peritoneal dialysis and haemodialysis |
100% of the agreed tariff at network providers, subject to pre-authorisation |
100% of the agreed tariff |
ADDITIONAL BENEFITS
PAID FROM MAJOR MEDICAL EXPENSES BENEFIT
| Benefits | Description | |
|---|---|---|
| Private Nursing |
100% of the agreed tariff and limited to R5 460 per beneficiary per month Subject to clinical motivation, pre-authorisation & case management by the Managed Health Care Organisation |
100% of the agreed tariff |
| Internal prostheses Appliances placed in the body as an internal adjuvant during an operation |
100% of the agreed tariff at network providers, subject to pre-authorisation and limited to R72 290 per Beneficiary per year Authorisation: 0800 765 432 |
100% of the agreed tariff |
| External Appliances Hearing aids, hearing aid repairs, wheelchairs, CPAP machines, external fixators and colostomy kits |
100% of the agreed tariff, subject to written motivation, which must be received 72 hours before the request for pre-authorisation Subject to the terms, conditions and protocols of the network DSP Limited to R54 050 per Beneficiary every two years Sublimits apply:
Authorisation: 0800 765 432 |
100% of the agreed tariff |
|
Medical and surgical appliances - including nebulisers, crutches, blood pressure machines, glucometers, etc. |
100% of the agreed tariff, subject to clinical motivation and approval Subject to the terms, conditions and protocols of the network DSP |
100% of the agreed tariff |