pre-authorization

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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 membership by ensuring only clinically necessary and cost-effective treatment is funded
  • inform members of the limit 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 clinical criteria, not on the availabilty of benefits and is not a guarantee of payment.

Benefits are funded subject to the benefits 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 as Scheme rules. Authorised services or treatment must commence within three months of authorisaion, after which the authorisation is no longer valid.

Authorisation does not include the fees charged by the attending medical practitioners, it is the member’s responsibilty 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.

Reimbursements of services that were authorised is dependent on the availability of funds at the time the Scheme receives the claim. Funds are not reserved when authorisation is granted.

Profmed does not prescribe the treatment members should undergo but will only fund treatment in accordance with the Scheme rules and protocols, and that is clinically appropriate and evidence-based, subject to PMB Legislation.

Where pre-authorisation is required, call 0860 776 363, or e-mail preauth@profmed.co.zaFrom within the SADC region call +27 12 679 4145.

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ELIGIBILITY
Membership of Profmed is only available to persons who have obtained:

  • A degree and/or qualification of four years or more
  • Two three-year degrees
  • A three-year degree with a post-graduate qualification of not less than one year

*Eligibility rules apply.

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