What is pre-authorisation ? As daunting and complicated as the term preauthorisation sounds , it ’ s actually quite simple to understand . All procedures that take place in a hospital must be pre-authorised . All pre-authorisation requests are evaluated against the Fund Rules and clinical funding policies .
Is a pre-authorisation the same as a quote ? No , it isn ’ t . It is important to obtain pre-authorisation but to also ask for a detailed quote from the hospital and medical practitioner prior to being admitted to hospital . The most important thing is to find out , prior to being admitted , what your medical aid will pay and what payment you might be responsible for . This gives you an opportunity to negotiate and eliminates any additional ‘ surprise ’ co-payments required after the procedure .
Co-payments differ from one medical scheme to another and are often higher than anticipated , mostly due to medical practitioners and hospitals charging higher than the medical aid rate .
The last thing you want to deal with is a surprise large co-payment and the stress related to that when you are recovering from a procedure .
When do I need to pre-authorise ? You must apply for a pre-authorisation reference number ( PAR ) as soon as a visit or admission to a hospital , CT scan , MRI scan or radio-isotope study is planned . It is best to do this at least two days before the procedure . You will also need pre-authorisation for :
• Renal clinic admissions for dialysis
• Procedures in doctor ’ s rooms instead of hospitalisation
• Physical rehabilitation care in rehabilitation facilities
• Drug and alcohol rehabilitation care in specific facilities
• Hospice admissions
• Oxygen therapy at home
• All specialised radiology
We need the following information when you preauthorise a procedure :
• Name and surname of the person having the procedure
• Membership number and dependant code
• The date of admission or procedure
• The diagnosis
• All proposed surgical procedure , diagnostic procedure or specialised radiology codes available ( ICD-10 , CPT , NRPL codes )
• The name of the facility where the procedure will take place
• The names and practice numbers of the healthcare professionals ( doctor , surgeon , specialist and so on .)
' In the event of emergency treatment or admission to hospital you must contact the call centre on the first working day after the incident .'
Bonitas Member Magazine Issue 2 | 2022
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