Glossary - Medshield
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Glossary

Glossary

Explanation of Terms

When allocated?

The period for which benefits and contributions apply, in this case 1 January to 31 December.

Chronic Disease/condition

A chronic condition is a condition that requires ongoing, long-term and continuous medical treatment.

Co-payments

Is the portion a member pays upfront at the point of service for specified services and procedures.

Designated Service Provider(DSP)

Providers appointed by Medshield to provide specified medical services to Medshield members.

Dispensing Fee

The Scheme’s negotiated fee charged by pharmacies when dispensing medication to members of the Scheme.

Exclusions

Services that are not covered in terms of the Rules of the Scheme.

ICD-10 Code

International Classification of Diseases (ICD-10) coding is a system that classifies diseases and the complications connected to these diseases according to a specific category.

In-hospital Benefits

Covers the major medical expenses you incur when you undergo a procedure or are admitted to hospital.

Medicine Access Card

Card sent to the member listing the medicines to be paid from the Chronic Medicine Benefit after registration for Chronic Medicine.

Medicine Price List

Reference pricing system that uses a benchmark or reference price for generically similar products. The fundamental principle of any reference price system is that it does not restrict a member’s choice of medicine but instead limits the amount that will be paid.

Out-of-hospital Benefits

Covers medical expenses incurred out of hospital, such as General Practitioner visits.

Pre-authorisation

The process whereby a member applies for approval with Medshield Hospital Management prior to hospital admission.

Pre-approval

The process whereby a member applies for approval for a procedure or treatment from the Scheme. This may include the submission of a motivation.

Prescribed Minimum Benefits (PMB)

The benefits to which the members are entitled.

Private Provider Rates (PPR)

The rates charged by private providers which are generally higher than the Scheme tariff.

PMB Care Template

Sound clinical guidelines to treat ailments and conditions that fall under the PMB regulation established by the Scheme as required by law.

Protocols

A set of pre-approved treatments authorised for PMB and other conditions and should be followed by service providers.

Retrospective Authorisation

The process where a member obtains a hospital authorisation number after an emergency admission, within 72 hours after the hospital admission.

Scheme Tariff

The rate determined by the Scheme.

Sub-limit

The maximum amount of cover for a specified medical expense.