FAQ

The Medshield Board of Trustees, appointed by the members of the Scheme, manage the affairs of the Scheme on behalf of the members according to the Medical Scheme’s Act of 1998 and the Scheme Rules.

• To familiarise yourself with the benefits offered and limits applicable to your chosen option.
• To inform Medshield of any changes to your membership and contact details.
• To review and check all information on accounts from service providers and statements received from Medshield.
• To obtain pre-authorisation prior to hospital admission.
• To register with the Scheme to access benefits pertaining to specified conditions.
• To keep your membership card in a safe place so that no one can use it without your permission
• To seek clarity from Medshield regarding your benefits, membership and any other information relating to the Scheme.
• To participate in the affairs of the Scheme (e.g. the appointment of the Board of Trustees).

The Scheme’s benefit year runs

from 1 January to 31 December, each year, with the exception of optical benefits which runs for a period of 2 years. This means that if you join the Scheme on 1 January, or you are an active member of the Scheme, you are entitled to the full allocation of benefits and limits.

However, if you join the Scheme during a benefit year, you are only entitled to a pro-rated proportion of the benefits and limits. If any of the benefits change during the year, the Board of Trustees will notify you accordingly.

• Make sure that you obtain service from providers who are in partnership with the Scheme.
• Talk to your doctor about more cost-effective generic alternatives for your prescribed medicines or, if you prefer, the dispensing pharmacist can assist in eliminating or reducing out of pocket expenses.
• Opt to use a General Family Practitioner as your primary caregiver instead of accessing a specialist directly.
• If treatment is recommended always check relevance, your available benefits and whether more cost effective alternative treatments are available.
• If an operation is scheduled for the afternoon or evening, please arrange for hospital admission after 12pm. A hospital admission after 12pm means that the Scheme only pays for the afternoon and not for the entire day.

To ensure that you get the best care possible, we offer you many value-added benefits through the various Managed Healthcare Programmes and partnerships. They are available to all Medshield members and have been created to give you the healthcare support that you need.

Carefully read through your Member Guide to familiarise yourself with benefits offered on your option and where to obtain service and treatment. Remember that we care and we are always there for you. Call the Medshield Contact Centre on 086 000 2120/+27 10 597 4701.

Before you or any of your registered dependants are admitted to hospital:

• Review which hospitals form part of the Medshield Hospital Network.
• Obtain hospital pre-authorisation.
• Hospital pre-authorisation remain the member’s responsibility but can be obtained by the member, medical practitioner or the hospital. You should register and obtain authorisation at least 72 hours before admission to the hospital. In case of an emergency admission, it is important to still obtain hospital authorisation on the first working day following the emergency admission.

• Pre-authorisation is a process where a member applies to the Scheme, before hospital admission, for approval of a procedure or treatment which requires hospital admission.
• The pre-authorisation process assesses the medical necessity and appropriateness of the procedure according to clinical protocols, guidelines and prior to hospital admission.

• Your hospital stay will be subject to the specific procedures and services that were pre-authorised by Medshield Hospital Management. Any additional days in hospital, multiple procedures or additional services will require further pre-authorisation or motivation.
• No further benefits will be covered or paid unless a longer stay or revised requirements are further authorised by the Scheme.
• There might be a requirement for additional information that needs to be submitted before an authorisation will be released.

• Internal prosthesis are artificially made substitutes which are surgically implanted for a diseased or missing part of the body.
• The list of available internal prosthesis are constantly reviewed and updated. If you want to explore new products or technologies, these will need to be motivated by your medical practitioner to the Scheme before surgery.
• Hip, knee, elbow or shoulder replacements and spinal fusion has to be pre-certified ten days before surgery to enable the case manager to negotiate discounts with the service providers.
• We recommend that you obtain a quotation from your treating doctor and contact the Scheme to ensure that you have sufficient benefits available to cover the costs.
• In the case of an emergency admission, retrospective authorisation must be obtained within 48 hours after the hospital admission. Should a member fail to obtain pre-authorisation, the Scheme will not settle any claims related to the admission.

Members can obtain hospital pre-authorisationeither telephonically or via SMS.

• The requested procedure is not covered by your specific Medshield option.
• The procedure does not qualify for funding from the in-hospital benefits; instead it is funded from out-of-hospital benefits.
• The procedure is not deemed appropriate at the specific time.
• The motivation was not received or was received after 3 days of the initial request.

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• In the event of a postponement of your admission or procedure, or if you are being re-admitted with the same condition, you need to contact Medshield Hospital Management and pre-authorise again with the revised details.

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• You need to cancel your hospital pre-authorisation. Contact Medshield Hospital Management and inform them of your intent to cancel the pre-authorisation.

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• Discuss the procedure in detail with your doctor prior to admission.
• Ask for the advantages and disadvantages of undergoing such a procedure prior to admission.
• Ask your doctor about the cost of the procedures, if possible ask the doctor to give you tariff codes for that specific procedure and contact Medshield to check if this will be covered by your available benefit limits and how much will be covered by Medshield.
• Where multiple procedures are performed during the same procedure, these may be covered at different percentages as set out in the tariff guidelines.
• Ask your doctor for alternatives before opting for surgery.
• Ask your doctor if he/she charges medical aid rates.
• Ask which anaesthetist will be used and query if he/she bills at medical aid rates.
• Certain procedures performed in the doctors’ rooms also require a pre-authorisation number. If you have obtained pre-authorisation for a procedure performed in the doctor’s rooms, the procedure will be covered under the major medical benefits and not your day-to-day benefits allowing your benefits to stretch.
• Certain procedures/scopes in doctors’ rooms does not require authorisation.
• The procedures/scopes will automatically be authorised when the Scheme receives the claim from the treating provider.
• The following procedures/scopes that does not require pre-authorisation includes:- Surgical excisions, Vasectomy, Prostate biopsy, Needle aspiration- Oesophagoscopy, Oesophageal pH studies, Upper GI endoscopy, Polypectomy endoscope, GI Tract Imaging, Colonoscopy, Sigmoidoscopy, Cystoscopy, Urethroscopy and Hysteroscopy.
• If these procedures are done in hospital, authorisation is required. Please refer to your Summary of Benefits for a list of procedures that can be performed in the doctors’ rooms.
• Important details about your pre-authorisation number: Your authorisation number only applies to the specific hospital or practice, which you indicated when you requested authorisation. If any details change you have to pre-authorise again. Any associated claims will be covered in accordance with the Scheme rules related to your specific option.
• Contact the Scheme for benefits on any related services that will not be on the hospital account, for example if you may need physiotherapy.

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• Any quotes sent to Medshield Hospital Management, as a motivation of the hospital authorisation, for a provider other than the hospital must be sent to the Scheme for confirmation of benefits.

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• The Medshield Hospital Network consists of various hospital groups who have entered into a formal agreement with Medshield to provide services to Medshield members at a reduced tariff.
• Through these partnerships Medshield is in a stronger position to negotiate for competitive tariffs and access when members are in need of medical attention.
• Using a hospital which forms part of the Medshield Hospital Network has many benefits but most importantly it allows members to maximise their benefits and enables Medshield to reduce the high costs related to hospital admissions.
• In a nutshell, the Medshield Hospital Network is a tool that enables the Scheme to ultimately manage one of the cost drivers that contribute to high medical premium increases annually

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Medshield Hospital Management will consider the following exceptions:

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It is not enough for a medical emergency to be diagnosed. Your condition is an emergency only if you require immediate treatment to prevent serious impairment to bodily function. This edition of Council for Medical Schemes (CMS) script aims to clarify the definition of an emergency: “All medical emergencies are prescribed minimum benefits (PMB''s) which require full payment from your medical scheme. However, diagnosis alone is not enough to conclude that a condition is a medical emergency. The condition must require immediate treatment before it can qualify as an emergency and subsequently, a PMB.”

Yes, all hospital admissions require pre-authorisation before admission and retrospective authorisation is required for emergencies. All hospital authorisations must be done with Medshield Hospital Management on 086 000 2121.

Members are free to acquire the services of any specialist of their choice. Medshield however, advises that members engage their specialists in advance regarding the use of a Medshield Network Hospital, should the need for hospital admission arise.

Ask your specialist whether or not he/she will be willing to attend to you at a hospital linked to the Medshield Hospital Network. This will allow you to make an informed decision, bearing in mind that an upfront 25% co-payment will apply if you opt to make use of any hospital outside of the Medshield Hospital Network.

Voluntary use of hospitals which do not form part of the Medshield Hospital Network will attract an upfront 25% co-payment from the member. It is important to note the following key points to avoid unnecessary out of pocket expenses:

• Voluntary use of a non-network hospital will attract a 25% co-payment
• Non-network hospitals charge private rates and not the Scheme negotiated rates. In summary the use of a non-network hospital will result in huge unnecessary expenses. Since you will be classified as a private admission to this hospital, you will be charged private rates which is normally double or three times the Medshield negotiated rate – and you will be responsible for settling the balance of this account as well as the difference in the rates. We therefore encourage members to make use of the Medshield Hospital Network to avoid huge out of pocket expenses.

A procedural co-payment is a co-payment applied to specified procedures. Procedural co-payments will apply in accordance with your option. Refer to your Summary of Benefits for more information.

Yes, the procedural co-payment will apply on benefit options that require co-payments even if members are admitted to a hospital which is linked to the Medshield Hospital Network. However, if hospital admission takes place outside of the Medshield Hospital Network, the procedural co-payment and the 25% co-payment will apply.

To find out which hospitals fall within this network, contact the Medshield Contact Centre on 086 000 2120 or visit Healthcare Professional on the website.

The Disease Management Programme has a holistic approach, focusing on the patients and using all the relevant hospital admission information and Scheme data relating to the specified diseases.

• The Disease Management Programme is managed by Medshield Hospital Management and members are identified for enrolment on the programme through the related hospital admission data and treatment.
• Patients receive one-on-one contact with a dedicated Case Manager who will advise them on the correct management of their condition in terms of medication and lifestyle modification, and will provide ongoing support. Should a member or dependant be diagnosed with a specific disease, it is compulsory to register on the applicable Disease Management Programme. Once the members have registered on the programme members will receive advice and information on how to manage the specified disease. Contact Medshield to register on the programme at 086 000 2121.
• Pathology or blood tests is when a sample of blood is taken for testing in a laboratory. Blood tests have a wide range of uses and are one of the most common types of medical test. For example, a blood test can be used to assess your general state of health, confirm the presence of a bacterial or viral infection, see how well certain organs, such as the liver and kidneys, are functioning or to screen for certain genetic conditions such as cystic fibrosis or spinal muscular atrophy.

• Ask your doctor about the need for blood tests to help with diagnosis of a medical condition. Suggest single instead of multiple tests for every condition.
• Obtain the cost of the blood tests.
• Ask your doctor to recommend suppliers who charges reduced rates.
• Ensure that the doctor uses the correct ICD-10 code so that the claim is paid from the correct benefit.

• Members who have proven to have prior credible medical scheme coverage, as stipulated in the Medical Schemes Act, are entitled to a range of minimum benefits. These benefits are known as Prescribed Minimum Benefits as set out in the regulations published in the Medical Schemes Act 131 of 1998.
• The cost of treatment for a PMB condition is covered, provided that the services are rendered by the Scheme’s Designated Service Provider (DSP) and according to the Scheme’s protocols and guidelines.

• Prescribed Minimum Benefits (PMB) is a set of defined benefits that ensures that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being, and to make healthcare more affordable.
• These costs are related to the diagnosis, treatment and care of the following three clusters.

• Ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits have run out, the medical scheme has to pay for the treatment of PMB conditions.
• Ensure that healthcare is paid for by the correct parties. Medshield members with PMB conditions are entitled to specified treatments which have to be covered by the Scheme.
• These specified PMB treatments includes treatment and medicines, subject to the use of Medshield’s Designated Service Provider treatment protocols and formularies.

• An emergency medical condition means the sudden and/or unexpected onset of a health condition that requires immediate medical or surgical treatment.
• If no treatment is available the emergency may result in weakened bodily function, serious and lasting damage to organs, limbs or other body parts or even death.

• Defined in the DTP list on the Council for Medical Schemes website. The Regulations to the Medical Schemes Act provide a long list of conditions identified as PMB conditions.
• The list is in the form of Diagnosis and Treatment Pairs. A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the 270 PMB conditions should be treated and covered.

• The Chronic Disease List (CDL) specifies medication and treatment for these conditions.
• To ensure appropriate standards of healthcare an algorithm published in the Government Gazette can be regarded as benchmarks, or minimum standards for treatment.

A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is Medshield’s first choice when its members need diagnosis, treatment or care for a PMB condition. If you choose not to use the DSP selected by the Scheme, you may have to pay a portion of the account as a co-payment. This could either be a percentage based co-payment or the difference between a DSP’s tariff and that charged by the provider you consulted.

If you choose not to use the DSP selected by Medshield, you may have to pay a portion of the account as a co-payment. Understanding your PMB benefit is key to having your claims paid correctly. One of the types of codes that appear on healthcare providers’ accounts is known as International Classification of Diseases, ICD-10 codes. These codes are used to inform the Scheme about what conditions members were treated for so that claims can be settled correctly. Understanding your PMB benefit is key to having your claims paid correctly.

More details than merely an ICD-10 code is required to claim for a PMB condition and ICD-10 codes are just one example of the deciding factors whether a condition is a PMB. In some instances you will be required to submit additional information to Medshield. In your current Medshield option you pay for a set of particular benefits. Your benefit option contains a basket of services that often has limits on the health services that will be covered by Medshield.

Because ICD-10 codes provide information on the condition you have been diagnosed with, these codes, along with other relevant information required by the Scheme, help Medshield to determine what benefits you are entitled to and how these benefits should be paid./p>

Medshield does not automatically pay PMB claims at cost as there is a possibility of over-servicing members with PMB conditions. Accordingly, it remains the members’ responsibility to contact the Scheme and confirm which PMB treatments were provided.

Final diagnosis determines if a condition is a PMB or not:

• When diagnosing whether a condition is a PMB, the doctor should look at the signs and symptoms at point of consultation. This approach is called a diagnosis-based approach.
• Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).

Only the final diagnosis will determine if the condition is a PMB or not.