Quick Links
Pre-authorisation at Profmed
medical aid scheme serves to:
- alert the medical aid scheme to upcoming costly expenses;
- allow the medical aid scheme to apply managed care interventions and protocols;
- limit the risk to the membership by ensuring only clinically necessary and cost-effective treatment is funded;
- inform members of the limits in respect of the procedure or treatment for which they are requesting authorisation; and
- give members the opportunity to query their benefits in respect of the procedure or treatment being authorised.
Pre-authorisation is based on a clinical decision and is not a guarantee of payment. Benefits are funded subject to the benefit limits and availability of funds at the time the claim is received by the Scheme for processing, and in accordance with the relevant protocols and Scheme rules. Authorised services or treatment must commence within three months of authorisation.
Authorisation does not include the fees charged by the attending medical practitioners, It is the member's responsibility to obtain pre-authorisation, which should be obtained at least seven days prior to the commencement of treatment or services. In case of after-hours emergencies, authorisation must be obtained the next working day.
