Hospital benefit

 

Unlimited benefits for hospitalisation

You enjoy unlimited benefits for all admissions to a private or state hospital of your choice, or a contracted network hospital if you are enrolled on one of our network benefit options. The most important thing to remember when you are admitted to hospital or to a psychiatric facility, is that your admission must be pre-authorised by Medihelp.

How hospital benefits work

Medihelp pays your hospital account at 100% of the Medihelp tariff*. The following benefits apply:

  • There is no overall annual limit on your hospital cover.
  • You may have to make procedure-specific co-payments on certain non-PMB procedures.
  • Certain sub-limits or maximum benefit amounts apply, e.g. for prostheses
  • An 80% benefit (20% co-payment) will apply if your hospital admission is not pre-authorised by Medihelp (non-emergencies).
  • A 65% benefit (35% co-payment) will apply if Prime Network and Necesse members are voluntarily admitted to non-network hospitals.
  • Members must pay any co-payments directly to the hospital on the day of the admission.

How to pre-authorise your hospital admission

All hospital admissions are subject to pre-authorisation, protocols and case management. You must obtain pre-authorisation for your planned hospital admission well in advance, or within 24 hours after an emergency admission. We offer you various ways to pre-authorise your hospital admission, including an online authorisation system which is available 24 hours a day, seven days a week, for your convenience.

You will need this information to pre-authorise:

  • Your membership number
  • The details of the patient
  • The procedure and diagnosis codes (get these from your doctor)
  • The treating doctor’s details
  • The details of the hospital to which the patient will be admitted
  • The date of admission
  • For certain procedures, additional information may be required, such as medical reports, X-rays or blood test results. Medihelp’s pre-authorisation consultant will advise you on what is needed.

Other ways to pre-authorise hospital admissions

 

Send email to

hospitalauth@medihelp.co.za

, phone Medihelp on 086 0200 678 or send a fax to 012 336 9535 to request pre-authorisation for your hospital admission or

click here

to use the online hospital authorisation

* Medihelp tariff refers to the tariff paid by Medihelp for different medical services, and can include the contracted tariff for services agreed with hospitals or the Medihelp Dental Tariff for dental services.

 

Procedure-specific deductibles

There are a limited number of low-incidence procedures that require a procedure-specific payment.  For more information and to view co-payments that may apply, click here


 

Dental procedures in hospital

Phone Dental Risk Company (DRC) on 012 741 8311 to get pre-authorisation for dental procedures to be performed in hospital. DRC manages Medihelp’s dental benefits, and they will inform you whether your benefit option covers the proposed treatment

The DRC consultants will need the following information:

  • Your membership number
  • The details of the patient
  • The procedure and diagnosis codes (get these from your dentist)
  • The treating dentist’s details
  • The details of the hospital or day clinic to which the patient will be admitted
  • The date of admission
  • Details of the anaesthetist
 

Private nursing

What is private nursing?

Private nursing is medical care provided by a registered nurse to sick or disabled patients. The care is provided in the patient’s home, at an institution such as a hospital or a nursing home, or at any other such facility.

Nurses or midwives must be registered with the South African Nursing Council to render services to patients.

What is general care?

General care refers to a service, irrespective of the point of such service, which can be rendered by a registered professional person or any other person in respect of a beneficiary, and which includes assistance with personal hygiene (bathing, dressing, changing incontinence diapers and similar assistance), catheter care, oral or tube feeding (excluding the placement of catheters and tubes), administering and/or supervision of oral, rectal, vaginal or topical medicine, assistance with mobilization and comfort care to prevent bedsores.

General care services are excluded from benefits.

Pre-authorisation

All private nursing services, excluding the administering of vaccines and stoma products, must be pre-authorised. A medical doctor must prescribe the services and must provide the following to Medihelp:

  • A written motivation
  • A treatment plan and written quotation which indicates the proposed period of treatment and the materials required for the treatment including the quantities
  • In the case of wound care, photos and/or a specialist report

You can email this information to

hmanagement@medihelp.co.za

or fax it to 012 336 9523.