Medical Scheme & Practical Information

This guide explains the practical and medical-scheme side of your care — authorisation, codes, possible costs, what to bring, and your privacy. A little preparation helps everything run smoothly.

1Pre-authorisation for surgery

• Planned procedures and hospital or day-case admissions usually need pre-authorisation from your medical scheme before the date.
• Obtaining authorisation is the member’s responsibility, but the rooms will give you the procedure and diagnosis (ICD-10) codes you need to arrange it.
• Authorisation confirms that the scheme will cover the admission — but it is not a guarantee of full payment of every fee.
• If authorisation is not obtained in time, your scheme may apply a penalty or decline the claim.

2Prescribed Minimum Benefits (PMBs)

• Some conditions and procedures are Prescribed Minimum Benefits, which schemes must cover according to the rules.
• Whether a specific operation qualifies depends on the diagnosis and your scheme’s rules — check with your scheme, quoting the codes the rooms provide.

3Codes, fees and possible shortfalls

• Claims use ICD-10 diagnosis codes and procedure codes. Note that ICD-10 codes usually come from the operation note or account, not from a device or requisition form.
• A specialist’s fee may be higher than the rate your scheme pays, which can leave a co-payment or shortfall. Ask the rooms about this in advance.
• Gap cover (a separate insurance product) is designed to help with these shortfalls, if you have it.
• For joint-replacement surgery, check your cover for the implant, and check your physiotherapy benefit for your rehabilitation.

4What to bring to the rooms

• Your ID and medical scheme card (and authorisation number for admissions).
• Your referral letter, if you have one.
• Any previous X-rays, ultrasound, CT or MRI scans and their reports — bring the actual images on disc, USB or a link, not just the report.
• A list of your current medication, supplements and allergies.
• Your questions — and a family member or friend if you would like one with you.

5Hospital admission — the practical side

• The rooms are at Suite 6, Netcare Pretoria East Hospital, Moreletapark, Pretoria.
• You will be told your admission time and fasting instructions in advance.
• Bring comfortable, loose clothing that opens at the front, and toiletries if staying overnight.
• Arrange for someone to drive you home, as you should not drive after an anaesthetic or while in a sling.

6Urgent problems and after hours

• In office hours, phone the rooms on 012 998 7550.
• For an urgent injury or problem after hours, go to your nearest casualty/emergency unit.
• For a life-threatening emergency, phone 10177 (ambulance) or 112 from a mobile.

7Your privacy

Your personal and health information is handled in line with South Africa’s Protection of Personal Information Act (POPIA) and the National Health Act. Your records are kept confidential and used to provide and administer your care. You may request access to your records under PAIA.

Cover, benefits and rules differ between schemes and plans and can change. Always confirm the details with your own medical scheme.