Dimension prime 1 network member guide 2018 - Aon South Africa
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September 2017
dimension prime 1 network
member guide 2018Dear Medihelp Member
Welcome to your product offering for 2018. At Medihelp, everything we do is developed to suit
your individual needs, and this guide will provide you with all the information you will need to
access your particular benefits, manage your Medihelp membership, enjoy the value of support
programmes and engage with us.
For ease of navigation, the guide has been divided into the following segments, making it easy to
find what you’re looking for:
product service
Your product has been developed to We dedicate user-centred online and offline
suit your unique healthcare needs support services to assist and support you in
managing your membership and benefits
value engagement
Based on your profile and healthcare We offer a variety of engagement
needs, we've developed programmes opportunities to establish convenient
and initiatives such as HealthPrint, our and effective two-way communication
free online wellness programme, to with you
add value
Warm regards
Heyn van Rooyen
Principal Officer
1contents (Click on the contents below to read more)
3 The right choice
service
product 37 Medihelp's Rules
37 Your membership card
4 A summary of your benefit option
38 Secured website for members
5 Additional insured benefits
38 Member app
6 Standard immunisation for children
39 Enrolment conditions
7 Benefits
39 Your dependants
7 Core benefits
40 Contributions
10 Procedure-specific co-payments
41 Benefit option interchange
11 Internally implanted prostheses
41 Summarised statements
12 Day-to-day benefits
42 Your details
13 General exclusions
43 Payments to Medihelp
14 Dental exclusions
43 Disputes
16 Supporting information on how to access
your benefits value
16 Hospitalisation and your network hospitals
44 HealthPrint
23 Prescribed minimum benefits (PMB)
45 élan health magazine
26 Emergency medical services
45 Healthcare support programmes
27 Medicine benefits
45 Oncology programme
29 Claims submission
47 HIV/Aids programme
29 Healthcare services rendered abroad
47 Back treatment programme
31 Pre-authorisation of certain services to
47 High-risk programme
access benefits
35 Explanation of terms engagement
48 Social media platforms
48 Annual general meeting (AGM)
48 Letters and emails
48 Advisers
49 Reporting fraud
50 Contact us
2the right choice
With a value-driven mindset we focus on fulfilling your health and
wellness needs and customise our products and services to ensure an
individualised experience when interacting with the Scheme in
terms of the following four key areas:
• Products • Services • Value • Engagement
A SOUND HEALTHCARE PARTNER SERVICE AND ENGAGEMENT
112 YEARS’ experience in the medical Our members’ service experience is measured at the
schemes industry point of engagement through voice-of-the-customer
research, allowing for constant feedback.
As a SELF-ADMINISTERED medical
scheme Medihelp maintains complete @
control and tightly manages all
administration costs 190 634
written enquiries
LARGE AND RELIABLE
Medihelp is one of the five largest
open medical schemes in South Africa
600 262 12 539
CLAIMS PAYMENT ABILITY is
calls answered mobile app users
guaranteed with our AA- rating
awarded by Global Credit Rating
4 734
CONSISTENCY
Medihelp’s average beneficiary age of
38 438 average hospital
social media followers admissions per month
37 years provides a healthy risk pool
to contribute to sustainability
OUR SOLVENCY LEVEL
Medihelp consistently maintains a
2 869 878 1 062 793
solvency level well above the industry
requirement
claims processed web visits per year
mySOS emergency Educational videos Call centre
This app ensures that you Effortless 60 helpful
and your loved ones can be empowerment consultants to
located in an emergency on relevant topics assist you
Member app Secured website
With an electronic membership card and An online hub with all your Medihelp
instant benefit verification service functionalities
3
Back to contentsproduct
The Dimension Prime 1 Network hospital plan is an affordable
solution if you are healthy, but want the assurance of cover for
private hospitalisation and minor day-to-day medical expenses.
You save 22% in monthly premiums as a member of the network
alternative with access to a quality network of 108 hospitals.
A summary of your benefit option
HOSPITAL BENEFITS (NO OVERALL
ANNUAL LIMIT)
108 network facilities
ESSENTIAL COVER
Diagnosis, treatment and care costs of
270 PMB and 26 chronic conditions
on the CDL
DSPs & specialist network apply
POST-HOSPITAL CARE
Up to 30 days after discharge
SPECIALISED RADIOLOGY
Unlimited in and out of hospital
Member pays the first R1 550 per examination
Balance paid at 100% of the MT
TRAUMA-RELATED BENEFITS
Including post-exposure prophylaxis in
Monthly contributions the event of sexual assault or accidental
exposure to HIV
Principal
R1 356
member ROAD & AIR TRANSPORT (Netcare 911)
Unlimited within RSA
24-hour helpline & trauma counselling
Dependant R1 104
INSURED DAY-TO-DAY BENEFITS
Child M = R1 100 per year
dependant R408 M+ = R2 200 per yearadditional insured benefits
Additional insured benefits which give you access
to pregnancy and baby-related benefits, screenings,
preventive and wellness services as well as a back
treatment programme.
Description Benefit
PREGNANCY AND BABY BENEFITS
12 per family per year
• Pregnancy consultations
• 2D sonars 2 per family per year
• First two consultations at a GP or specialist 2 per baby < 1 year
SCREENING AND WELLNESS BENEFITS*
On request of a medical doctor
(Doctor’s consultation paid from available day-to-day benefits)
1 pathology test per
• Pap smear (item codes 4566/4559)
beneficiary per year
• Prostate test (PSA level) for males > 40 years (item code 4519)
• FOBT for beneficiaries > 50 years (item code 4351)
• Mammogram for females > 40 years (item codes
3605/39175/34100/34101) 1 radiology exam per
• Bone mineral density test (BMD) for females > 50 years beneficiary per year
(item codes 3604/50120)
AVAILABLE AT OUR WELLNESS PROVIDERS CLICKS AND
DIS-CHEM PHARMACY CLINICS*:
• Voluntary HIV testing and counselling Unlimited
• Blood glucose or total cholesterol or combination test (blood
1 per beneficiary per year
glucose, total cholesterol, BMI and blood pressure measurement)
DIETICIAN CONSULTATION 1 consultation per
If BMI test result at wellness provider indicates a BMI > 30 and if registered HealthPrint
registered on HealthPrint (item codes 84200-84205) beneficiary per year
IMMUNISATIONS
Administering fee at Clicks or Dis-Chem pharmacy clinics included
• Standard immunisations schedule as published by the Standard schedule per
Department of Health for beneficiaries < 7 years beneficiary
• Flu vaccine
1 per beneficiary per year
• Tetanus vaccine
• HPV vaccine – protocols apply:
2 injections per beneficiary
• 10 – 14 years
• 15 – 26 years 3 injections per beneficiary
PNEUMOVAX VACCINE
1 vaccine per beneficiary in
• Patients registered on Medihelp’s asthma or COPD treatment
a 5-year cycle
programme (NAPPI code 755826027) for beneficiaries > 55 years
BACK TREATMENT AT A DBC FACILITY 1 programme per
Subject to protocols and pre-authorisation beneficiary per year
* These benefits are not available if you have been registered for a chronic/PMB condition as it is no longer considered as preventive care.
Benefits are paid at 100% of the MT.
BMI – Body mass index PMB – Prescribed minimum benefits HPV – Human papilloma virus
FOBT – Faecal occult blood test COPD – Chronic obstructive pulmonary disease DBC – Document-Based Care
GP – General practitioner MT – Medihelp tariff (see definition on page 36)
5
Back to contentsStandard immunisation for children
Your benefit option offers benefits for standard immunisation for children younger
than seven years old and it is important to get these immunisations as stipulated in the
Department of Health’s Expanded Programme on Immunisation (EPI). If you do not have
your child vaccinated at the precise ages indicated in the table below, the cost of the
vaccines will not be covered. Join HealthPrint, Medihelp's free online wellness programme
and register for our toddler programme where you'll get newsletters and reminders to
vaccinate your little one. See page 44 for more information.
At birth 6 months
• BCG for TB • Measles vaccine (1)
• Oral polio vaccine
9 months
6 weeks • Pneumococcal conjugated vaccine
• Oral polio vaccine • Chickenpox vaccine
• Rotavirus vaccine
• Diphtheria, tetanus,
acellular pertussis, 12 months
inactivated polio vaccine • Measles vaccine (2)
and haemophilus influenzae
type B and Hepatitis B
vaccine combined (1) 18 months
• Pneumococcal conjugated • Diphtheria, tetanus, acellular
vaccine pertussis, inactivated polio
vaccine and haemophilus
influenzae type B and Hepatitis B
10 weeks vaccine combined (4)
• Diphtheria, tetanus,
acellular pertussis,
inactivated polio vaccine 6 years
and haemophilus influenzae • Tetanus and diphtheria vaccine
type B and Hepatitis B
vaccine combined (2)
14 weeks
• Rotavirus vaccine
• Diphtheria, tetanus,
acellular pertussis,
inactivated polio vaccine
and haemophilus influenzae
type B and Hepatitis B
vaccine combined (3)
• Pneumococcal conjugated
vaccine
6
Back to contentsbenefits
Core benefits
Description Benefit
DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB
AND 26 CHRONIC CONDITIONS ON THE CDL
Subject to protocols, pre-authorisation and DSPs 100% of the cost
PMB
Unlimited
Co-payments may apply
in case of voluntary
non-DSP use/protocol deviation
BENEFITS FOR MAJOR TRAUMA THAT NECESSITATES
HOSPITALISATION IN THE CASE OF:
• Motor vehicle accidents 100% of the cost
• Stab wounds Unlimited
• Gunshot wounds
Trauma
• Head trauma
• Burns
• Near drowning
Subject to authorisation, PMB protocols and case
management
POST-EXPOSURE PROPHYLAXIS
EMERGENCY TRANSPORT SERVICES (Netcare 911)
RSA, Lesotho, Swaziland, Mozambique, Namibia and Botswana
Subject to pre-authorisation and protocols
• In beneficiary’s country of residence:
• Transport by road 100% of the MT
• Transport by air Unlimited
50% co-payment if not
pre-authorised
• Outside beneficiary’s country of residence
• Transport by road 100% of the MT
EMS
R1 900 per case
50% co-payment if not
pre-authorised
• Transport by air 100% of the MT
R12 400 per case
50% co-payment if not
pre-authorised
24-HOUR HELPLINE AND TRAUMA COUNSELLING
Phone 082 911
(Netcare 911)
CDL – Chronic Diseases List DSP – Designated service provider
EMS – Emergency medical services PMB – Prescribed minimum benefits
MT – Medihelp tariff (see definition on page 36)
7
Back to contentsCore benefits
Description Benefit
HOSPITALISATION (network hospitals and day clinics)
Subject to pre-authorisation, protocols and case management
• Intensive and high care wards 100% of the MT
• Ward accommodation Unlimited
• Theatre fees Procedure-specific co-payments
• Treatment and ward medicine may apply (non-PMB cases)
• Consultations, surgery and anaesthesia 20% co-payment per admission if
not pre-authorised
35% co-payment on voluntary
non-network admissions
POST-HOSPITAL CARE
Professional services relating to a Medihelp authorised private
hospital admission, required for up to 30 days after discharge 100% of the MT
(Prescribed medicine and medical appliances are paid from M = R1 700 per year
available benefits) M+ = R2 300 per year
• Speech therapy
• Occupational therapy
• Physiotherapy
PROCEDURE-SPECIFIC CO-PAYMENTS See page 10
PROSTHESES See page 11
CONFINEMENT (childbirth)
Subject to pre-authorisation, protocols and case management 100% of the MT
Unlimited
20% co-payment per admission if
not pre-authorised
HOME DELIVERY
Subject to pre-authorisation 100% of the MT
• Professional nursing fees R11 900 per event
• Equipment 20% co-payment per event if not
• Material and medicine pre-authorised
STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL
TECHNOLOGIST SERVICES
In hospital 100% of the MT
Subject to clinical protocols Unlimited
SPECIALISED RADIOLOGY 100% of the MT
In and out of hospital Unlimited
On request of a specialist and subject to clinical protocols Member pays the first R1 550 per
• MRI and CT imaging (subject to pre-authorisation) examination
• Angiography 100% of the MT
Unlimited
ORGAN TRANSPLANTS (PMB only)
Subject to pre-authorisation and clinical protocols 100% of the cost
Unlimited
• Cornea implants 100% of the MT
R26 100 per implant per year
MT – Medihelp tariff (see definition on page 36) PMB – Prescribed minimum benefits
MRI – Magnetic resonance imaging M – Member
CT – Computerised tomography
8
Back to contentsCore benefits
Description Benefit
SUPPLEMENTARY HEALTH SERVICES
In hospital
• Occupational and speech therapy, dietician services, audiometry, 100% of the MT
podiatry, massage, orthoptic, chiropractic, homeopathic, herbal Unlimited
and naturopathic, osteopathic and biokinetic services
• Physiotherapy on referral by the attending medical doctor
OXYGEN
In hospital 100% of the MT
Unlimited
NEUROSTIMULATORS
Subject to pre-authorisation and clinical protocols
• Device and components 100% of the MT
R101 200 per beneficiary per year
RENAL DIALYSIS
100% of the MT
In and out of hospital
Unlimited
Subject to pre-authorisation and clinical protocols
APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND
CHARGED BY THE HOSPITAL ON DISCHARGE FROM THE 100% of the MT
HOSPITAL (TTO) R330 per admission
(Excluding PMB chronic medicine)
PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION
Subject to pre-authorisation, services rendered in an approved
network hospital/facility and prescribed by a medical doctor
• Professional services rendered in and out of hospital by a 100% of the MT
psychiatrist R17 600 per beneficiary per year
• General ward accommodation (maximum R26 500 per family
• Medicine supplied during the period of the treatment in per year)
the institution 20% co-payment per admission if not
• Outpatient consultations pre-authorised
ONCOLOGY
Subject to pre-authorisation and registration on the Medihelp
Oncology Management Programme. Protocols, DSP and MORP apply.
• PMB cases 100% of the MT
Hospital and related cancer treatments and services, including Unlimited
bone marrow/stem cell transplants (subject to PMB legislation) Co-payments apply to voluntary
non-network services (10%) and/or
deviating from protocol (20%)
• Non-PMB cases 100% of the MT
Hospital and related cancer treatments, including radiotherapy, R80 000 per family per year
brachytherapy, chemotherapy and associated adjuvant medicine Co-payments apply to voluntary
non-network services (10%) and/or
deviating from protocol (20%)
HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES AS AN 100% of the MT
ALTERNATIVE TO HOSPITALISATION Unlimited
Subject to pre-authorisation, and services rendered in an approved 20% co-payment per admission if
facility and prescribed by a medical doctor not pre-authorised
DSP – Designated service provider PMB – Prescribed minimum benefits
MORP – Medihelp Oncology Reference Price TTO – To take out (medicine)
9 MT – Medihelp tariff (see definition on page 36)
Back to contentsCore benefits
Description Benefit
PRIVATE NURSING AS AN ALTERNATIVE TO
100% of the MT
HOSPITALISATION
20% co-payment per event if not
Subject to pre-authorisation
pre-authorised
(Excluding general day-to-day care)
APPENDECTOMY
Subject to pre-authorisation
• Conventional procedure 100% of the MT
Unlimited
• Laparoscopic procedure 100% of the MT
Hospitalisation:
R15 800 per beneficiary
PROSTATECTOMY
Subject to pre-authorisation
• Conventional or laparoscopic procedure 100% of the MT
Unlimited
• Robotic assisted laparoscopic procedure 100% of the MT
Hospitalisation:
R100 400 per beneficiary
Procedure-specific co-payments
Description Co-payment
All hospital admissions are subject to pre-authorisation, protocols 100% of the MT
and case management 20% co-payment per admission if
not pre-authorised
35% co-payment on voluntary
non-network admission
NECK AND BACK FUSIONS R10 600 per admission
ENDOSCOPIC PROCEDURES
• In the doctor’s rooms No co-payment
Gastroscopy and colonoscopy
• In a day clinic
R1 950 per admission
Gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
• In hospital
R2 950 per admission
Gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA R2 900 per admission
In hospital
Subject to pre-authorisation and DSP's managed care protocols Only for removal of impacted teeth
(item codes 8941/8943/8945 on
dentist’s account) and extensive
dental treatment for children
younger than 5 years – once per
lifetime (Dentist's account – for
member's account)
MT – Medihelp tariff (see definition on page 36) DSP – Designated service provider 10
Back to contentsInternally implanted prostheses
Description Benefit
All hospital admissions are subject to pre-authorisation, protocols 100% of the MT
and case management 20% co-payment per admission if
not pre-authorised
35% co-payment on voluntary
non-network admission
The member is liable for the
difference in cost should PMB spinal,
hip, knee and cardiac prostheses not
be obtained from the DSP
INTERNALLY IMPLANTED PROSTHESES
• EVARS prosthesis R31 400 per beneficiary per year
• Vascular/cardiac prosthesis R31 400 per beneficiary per year
• Health-essential functional prosthesis R20 900 per beneficiary per year
• Hip, knee and shoulder replacements Hospitalisation: 100% of the MT
In case of acute injury where replacement is the only Prosthesis: Health-essential
clinically appropriate treatment modality, subject to functional prosthesis benefits apply
protocols (non-PMB cases)
Replacements due to wear and tear are excluded from
benefits
• Intra-ocular lenses Sub-limit subject to health-
essential functional prosthesis
benefit
2 lenses per beneficiary per year
R3 800 per lens
• Prosthesis with reconstructive or restorative surgery
In and out of hospital
R3 900 per family per year
• External breast prostheses
In and out of hospital
MT – Medihelp tariff (see definition on page 36)
PMB – Prescribed minimum benefits
DSP – Designated service provider
EVARS – Endovascular aortic replacement surgery
11
Back to contentsDay-to-day benefits
Description Benefit
GPs AND SPECIALISTS
Consultations and follow-up consultations 100% of the MT
M = R1 100 per year
PHYSIOTHERAPY
M+ = R2 200 per year
Treatment and material
MEDICINE
Medicine obtained in the Medihelp Preferred Pharmacy Network
• Acute medicine 100% of the MMAP if generic
• Self-medication medicine is used
• Contraceptives
80% of the MT if no generic
medicine is available
70% of the MMAP if original
medicine is used voluntarily
although generic medicine is
available
• PMB chronic medicine 100% of the MHRP
Subject to pre-authorisation and registration on Medihelp’s Unlimited
PMB medicine management programme Formulary and DSP apply –
60% co-payment if not obtained
from DSP*
OPTOMETRY For member’s account
EMERGENCY UNITS AND SUPPLEMENTARY HEALTH SERVICES For member’s account
OXYGEN
Out of hospital 100% of the MT
Subject to pre-authorisation, clinical protocols and services Unlimited
prescribed by a medical doctor 20% co-payment if not
pre-authorised
DENTAL SERVICES
• Conservative dental services For member’s account
• Dental procedures under conscious sedation in the dentist’s 100% of the MT
chair (sedation cost) Removal of impacted teeth only
Subject to pre-authorisation and DSP's managed care (Dentist’s account only for item
protocols codes 8941/8943/8945)
20% co-payment if not
pre-authorised
• Specialised dental services For member’s account
STANDARD RADIOLOGY For member’s account
MHRP – Medihelp Reference Price GP – General practitioner
MT – Medihelp tariff (see definition on page 36) M – Member
PMB – Prescribed minimum benefits MMAP – Maximum Medical Aid Price
DSP – Designated service provider
* DSP: • PMB chronic medicine – MobileMeds and DSP network
• Oncology medicine – Dis-Chem Oncology/Medipost
• HIV/Aids medicine – Halocare/Dis-Chem Direct/Medipost
12
Back to contentsDay-to-day benefits
Description Benefit
PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
For member’s account
Out of hospital
EXTERNAL PROSTHESES, MEDICAL, SURGICAL AND
ORTHOPAEDIC APPLIANCES
In and out of hospital
• Artificial eyes 100% of the MT
R4 300 per family per 3-year cycle
• Speech and hearing aids 100% of the MT
R4 300 per family per 3-year cycle
• Artificial limbs 100% of the MT
R4 300 per family per 3-year cycle
• Wheelchairs 100% of the MT
R4 300 per family per 3-year cycle
• Hyperbaric oxygen treatment
For member’s account
• Medical appliances
• Stoma components 100% of the MT
• Incontinence products/supplies Unlimited
• CPAP apparatus 100% of the MT
Prescribed by a medical doctor R8 850 per beneficiary per
24-month cycle
CPAP – Continuous positive airway pressure MT – Medihelp tariff (see definition on page 36)
This is a summary of benefits. In the event of a dispute, the registered Rules of Medihelp will apply (which are subject to approval by the Council
for Medical Schemes). If a beneficiary joins during the course of a financial year, the benefits are calculated pro rata according to the remaining
number of months per year.
General exclusions
General • The completion of medical and other questionnaires/
• Services which are not mentioned in the Rules as certificates not requested by Medihelp and the services
well as services which in the opinion of the Board of related thereto, including medical tests for career
Trustees, are not aimed at the generally accepted purposes or recreational activities.
medical treatment of an actual or a suspected medical • Costs for evidence in a lawsuit.
condition or handicap, which is harmful or threatening • Costs exceeding the scheme tariff for a service or
to necessary bodily functions (the process of ageing is the maximum benefit to which a member is entitled,
not considered to be a suspected medical condition or subject to PMB.
handicap). • Appointments not kept.
• Travelling and accommodation/lodging costs, including
meals as well as administration costs of a beneficiary Medical conditions
and in the case of a service provider, where such costs • The treatment of infertility, other than that stipulated in
do not relate to a PMB condition. the Regulations to the Medical Schemes Act, 1998.
• Aptitude, intelligence/IQ and similar tests as well as the • Treatment of alcoholism and drug abuse as well as
treatment of learning problems. services rendered by institutions which are registered in
• Operations, treatments and procedures – terms of the Prevention of and Treatment for Substance
• of own choice; Abuse Act 70 of 2008 or other institutions whose
• for cosmetic purposes; and services are of a similar nature, other than stipulated in
• for the treatment of obesity, with the exception of the the Regulations to the Medical Schemes Act, 1998.
treatment of obesity which is motivated by a medical • Treatment of impotence.
specialist as life-threatening and approved
beforehand by Medihelp.
13
Back to contentsProcedures and services exemptions in terms of section 21 of the
• The artificial insemination of a person as defined in the Medicines and Related Substances Control
National Health Act 61 of 2003. Act 101 of 1965 as amended;
• Immunisation (including immunisation procedures and • homeopathic and naturopathic medicine
material) which is required by an employer, excluding items that have valid NAPPI codes; and
flu immunisations and standard child immunisations. • where well-documented, sound evidence-
• Exercise, guidance and rehabilitation programmes. based proof exists of efficacy and cost-
• Services rendered by social workers. effectiveness.
• Costs of visits at home and home programmes. • All biological and other medicine items as per
• When only accommodation is provided and/or general Medihelp’s medicine exclusion list.
care services rendered. • High technology treatment modalities, surgical devices
• The cost of transport with an ambulance/emergency and medication.
vehicle – • Combination analgesic medicine, including opioid and
• from a hospital/other institution to a residence; opioid combination analgesic medicine items claimed
• in the event of a visit to friends/family; and from acute medicine benefits exceeding 360 units per
• to the rooms of a medical doctor when the objective beneficiary per year.
of the visit/consultation/treatment does not pertain • Non-steroidal anti-inflammatory medicine claimed
to admission in a hospital. from acute medicine benefits exceeding 180 units per
• The cost of harvesting and/or preserving human tissues, beneficiary per year.
including, but not limited to, stem cells, for future use • Child and adult nappies.
thereof to treat a medical condition which has not yet • Smoking cessation and anti-smoking preparations.
been diagnosed in a beneficiary. • Medicine derived from blood products.
• Pathology services requested by a person other than a
medical doctor. Appliances
• Radiology services requested by a person other than • Blood pressure apparatus.
a medical doctor, with the exception of a chiropractor • Commode.
who may request black and white X-rays. • Toilet seat raiser.
• Emergency room facility fees. • Hospital beds for use at home.
• Breast augmentation. • Devices to improve sight.
• Breast reduction. • Mattresses and pillows.
• Gastroplasty. • Bras without external breast prostheses.
• Gender reversal operations. • Insulin pumps and consumables.
• Lipectomy. • Back, arm and neck support, crutches, orthopaedic
• Epilation. footwear and elastic stockings.
• Otoplasty/reconstruction of the ear. • Implantable hearing devices.
• Refractive procedures. • Peak flow measurement apparatus.
• Sclerotherapy.
• PET (Positron emission tomography). Dental exclusions
• Clinical psychology and psychiatric nursing.
• Hyperbaric oxygen treatment. Oral hygiene
• Optometric services. • Oral hygiene instruction and evaluation.
• Physiotherapy services associated with the removal of • Professionally applied fluoride for beneficiaries younger
impacted wisdom teeth and in-hospital services not than 5 years and 13 years and older.
referred by the attending medical doctor. • Nutritional and tobacco counselling.
• Cost of prescribed toothpastes, mouthwashes (e.g.
Medicines, consumables and other products Corsodyl) and ointments.
• Bandages, cotton wool, dressings, plasters and similar • Fissure sealants on patients 16 years and older.
materials that are not used by a supplier of service • Dental bleaching.
during a treatment/procedure.
• Food substitutes, food supplements and patent food, Fillings/restorations
including baby food. • Fillings to restore teeth damaged due to toothbrush
• Multivitamin and multi-mineral supplements alone or in abrasion, attrition, erosion and fluorosis.
combination with stimulants (tonics). • Resin bonding for restorations charged as a separate
• Appetite suppressants. procedure to the restoration.
• All patent substances, suntan lotions, anabolic • Polishing of restorations.
steroids, contact lens solutions as well as substances • Gold foil restorations.
not registered by the South African Medicines Control • Ozone therapy.
Council, except medicine items approved by Medihelp in • Replacement of amalgam (silver) fillings with composite
the following instances – (white) fillings.
• medicine items with patient-specific
14
Back to contentsRoot canal therapy and extractions Periodontics
• Root canal therapy on primary (milk) teeth. • Surgical periodontics, which includes gingivectomies,
• Direct and indirect pulp capping procedures. periodontal flap surgery, tissue grafting and hemisection
• Root canal treatment on wisdom teeth (3rd molars). of a tooth.
• Perio chip placement.
Plastic dentures/snoring appliances/mouth guards
• Diagnostic dentures and the associated laboratory costs. Maxillofacial surgery and oral pathology
• Snoring appliances and the associated laboratory costs. • Orthognathic (jaw correction) and other orthodontic-
• Provisional dentures and associated laboratory costs. related surgery and any related hospital cost and
• The clinical fee of denture repairs, denture tooth laboratory costs.
replacements and the addition of a soft base to new • Bone augmentations.
dentures. (The laboratory fee will be covered at the • Bone and other tissue regeneration procedures.
Medihelp tariff where managed care protocols apply.) • Cost of bone regeneration material.
• The laboratory cost associated with mouth guards. (The • The auto-transplantation of teeth.
clinical fee will be covered at the Medihelp tariff where • Sinus lift procedures.
managed care protocols apply.) • The closure of an oral-antral opening (item code 8909)
• High impact acrylic. when claimed during the same visit with impacted teeth
• Cost of gold, precious metal, semi-precious metal and (item codes 8941, 8943 and 8945).
platinum foil.
• Laboratory delivery fees. Hospitalisation (general anaesthetic)
• Where the reason for admission to hospital is fear or
Partial metal frame dentures anxiety for dental procedures.
• Metal base to partial and full dentures, including the • Multiple hospital admissions.
laboratory cost. • Where the only reason for admission to hospital is to
• High impact acrylic. acquire a sterile facility.
• Cost of gold, precious metal, semi-precious metal and • The cost of dental materials for procedures performed
platinum foil. under general anaesthesia.
• Laboratory delivery fees. • The hospital and anaesthetist claims for the following
procedures will not be covered when performed under
Crowns and bridges general anaesthesia:
• Crowns or crown retainers on wisdom teeth • Apicectomies.
(3rd molars). • Dentectomies.
• Pontics on 2nd molars. • Frenectomies.
• Crown and bridge procedures for cosmetic reasons and • Conservative dental treatment (fillings, extractions
the associated laboratory costs. and root canal therapy) in hospital for adults.
• Crown and bridge procedures where there is no • Professional oral hygiene procedures.
extensive tooth structure loss and associated laboratory • Implantology and associated surgical procedures.
costs. • Surgical tooth exposure for orthodontic reasons.
• Occlusal mouth rehabilitations and the associated
laboratory costs. Additional Scheme exclusions
• Provisional crowns and the associated laboratory costs. • Special reports.
• Porcelain veneers, inlays and the associated laboratory • Dental testimony, including dento-legal fees.
costs. • Behaviour management.
• Emergency crowns that are not placed for immediate • Intramuscular and subcutaneous injections.
protection in tooth injury, and the associated laboratory • Procedures that are defined as unusual circumstances
costs. and unlisted procedures.
• Cost of gold, precious metal, semi-precious metal and • Appointments not kept.
platinum foil. • Treatment plan completed (item code 8120).
• Laboratory delivery fees. • Electrognathographic recordings, pantographic
recordings and other such electronic analyses.
Orthodontics • Caries susceptibility and microbiological tests.
• Orthodontic treatment for cosmetic reasons and • Pulp tests.
associated laboratory costs. • Cost of mineral trioxide.
• Orthodontic treatment for beneficiaries younger than • Enamel microabrasion.
9 and 18 years and older. • Implants.
• Orthodontic re-treatment and the associated laboratory
costs.
• Cost of invisible retainer material.
• Laboratory delivery fees.
• Orthodontic-related surgery.
15
Back to contentsSupporting information on how to access your benefits
Hospitalisation and your network hospitals
Members of Dimension Prime 1 Network must be admitted to network hospitals or day
clinics when they need to undergo planned procedures.
Specialist services
Remember – certain specialists only admit patients to the hospital where they have
their consultation rooms, so you’ll have to make sure that your specialist operates at
a network hospital. A specialist network for the Dimension Prime network options is
available for prescribed minimum benefits (PMB) services to contain co-payments.
Where to find a network hospital
iOS Android Windows
Our website lists all the network hospitals. Download our Medihelp member app, which
Visit www.medihelp.co.za. is available on the above devices.
Going to hospital? Remember to pre-authorise
Planned admissions
All hospital and day clinic admissions: pre-authorise well in advance because
we may need more information from your doctor, e.g. test results or reports.
This will ensure that you do not have to make a 20% co-payment. A 35%
co-payment will apply to voluntary admissions to non-network hospitals.
Emergency admissions
Authorise on the 1st workday after admission.
How to pre-authorise your hospital admission
There are various ways to pre-authorise your hospital admission and we’ve developed an
automated authorisation system that provides immediate authorisation 24 hours a day,
seven days a week for 19 procedures.
16
Back to contentsImmediate e-auth
Procedures that can be automatically authorised
Adenoidectomy Dilatation and curettage Myomectomy
Appendectomy Gastroscopy Myringotomy
Caesarean section Hysterectomy Normal birth
Cholecystectomy Hysteroscopy Sterilisation
Circumcision Intra-uterine devices Tonsillectomy
Colonoscopy Laparoscopy Vasectomy
Cysto-urethroscopy
E-auth process
Step 1 – Visit Medihelp’s website at www.medihelp.co.za
Step 2 – Look for the Login/Register block, select “Members” to go to the secured site for
members and click on Login/Register. If you need to register, select “Register”, follow the easy
steps to register and then log on to the secured site for members.
Step 3 – Click the “Pre-authorisation” button on the menu and select “Hospital authorisation”.
Then follow the steps to authorise your hospital admission and within moments you will receive
details of the pre-authorisation via SMS and an email with your reference number.
Approval of other procedures
Apply via Medihelp’s secured site for members or use one of the authorisation channels listed
below.
Other ways to apply for pre-authorisation
Authorise via our member app for smartphones
Download the app from iStore and GooglePlay iOS Android Windows
Other authorisation channels
Email Phone Fax Dental
hospitalauth@medihelp.co.za 086 0200 678 012 336 9535 086 0200 678
012 741 5143
17
Back to contentsInformation you need to pre-authorise
• Your membership number and details
• The details of the patient
• The procedure and diagnosis codes (get these from your doctor)
• The treating doctor’s details and practice number
• The details of the hospital to which the patient will be admitted and practice number
• The date and time of admission
• For certain procedures, additional information may be required, such as medical reports,
X-rays or blood test results. Medihelp’s pre-authorisation consultant will advise you on
what is needed.
• Details of the anaesthetist (for dental procedures).
Dimension Prime hospital and day clinic network
Gauteng
City/town Name Practice No
Alberton Clinton Clinic 5708877
Alberton Union Hospital 5804981
Benoni Linmed Hospital 5808588
Florida Mayo Clinic 7700164
Johannesburg Garden City Clinic 5805988
Johannesburg Mulbarton Hospital 5808278
Johannesburg Park Lane Clinic 5803004
Johannesburg Rand Clinic 5804620
Kempton Park Birchmed Surgical Centre 7700504
Krugersdorp Bellstreet Hospital 5808731
Krugersdorp Krugersdorp Private Hospital 5808111
Krugersdorp Pinehaven Hospital 604968
Midrand Cure Day Clinics (Midstream) 423556
Pretoria Akasia Hospital 5808618
Pretoria Brooklyn Surgical Centre 7700318
Pretoria Cure Day Clinics (Erasmuskloof) 448087
Pretoria Intercare Day Hospital (Hazeldean) 472395
Pretoria Jakaranda Hospital 5804116
Pretoria Louis Pasteur Hospital 5808820
18
Back to contentsGauteng
City/town Name Practice No
Pretoria Medkin Clinic 7700121
Pretoria Montana Private Hospital 5809002
Pretoria Pretoria East Private Hospital 5808855
Pretoria Unitas Hospital 5808138
Pretoria Zuid-Afrikaans Hospital 5805112
Springs East Rand N17 Private Hospital 5809029
Vanderbijlpark Cormed Clinic 5709113
Vanderbijlpark Mediclinic Emfuleni 5808375
P J Schutte Theatre Unit
Vanderbijlpark 7600534
(dental procedures only)
Vereeniging Mediclinic Vereeniging 5808081
Vereeniging Midvaal Private Hospital 5808898
KwaZulu-Natal
City/town Name Practice No
Amanzimtoti Kingsway Hospital 5808200
Ballito Alberlito Hospital 250562
Durban Chatsmed Garden Hospital 5808219
Durban Hillcrest Private Hospital 426563
Durban Nu-Shifa Hospital 5808464
Durban St Augustine’s Hospital 5802563
Howick Mediclinic Howick 122092
Ladysmith La Verna Hospital 5808235
Newcastle Mediclinic Newcastle 5808871
Pietermaritzburg Mediclinic Pietermaritzburg 5808073
Pietermaritzburg St Anne’s Hospital 5808197
Pinetown The Crompton Hospital 5808596
Port Shepstone Hibiscus Hospital 5808901
Richards Bay The Bay Hospital 5808472
Shelly Beach Shelly Beach Day Clinic 380059
Umhlanga Umhlanga Hospital 5808936
Umhlanga KZN Day Clinic 534463
19
Back to contentsLimpopo
City/town Name Practice No
Bela-Bela St Vincent’s Hospital 5706548
Lephalale Marapong Private Hospital 5708125
Makhado Zoutpansberg Private Hospital 253871
Polokwane Mediclinic Limpopo 5808189
Polokwane Mediclinic Limpopo Day Clinic 0603120
Tzaneen Mediclinic Tzaneen 132454
Mpumalanga
City/town Name Practice No
eMalahleni eMalahleni Day Hospital 7700520
eMalahleni eMalahleni Private Hospital 413615
Ermelo Mediclinic Ermelo 5808863
Middelburg Middelburg Private Hospital 5808243
Nelspruit Kiaat Private Hospital 558818
Nelspruit Lowveld Hospital 463345
Nelspruit Mediclinic Nelspruit 5808340
Secunda Mediclinic Secunda 540110
North West
City/town Name Practice No
Klerksdorp Sunningdale Hospital 5706696
Klerksdorp Wilmed Park Private Hospital 5808812
Potchefstroom Potchefstroom Medical and Dental Centre 7700784
Rustenburg Ferncrest Hospital 5808391
Vryburg Vryburg Private Hospital 5808553
Northern Cape
City/town Name Practice No
Kimberley Mediclinic Kimberley 5808049
Upington Mediclinic Upington 5808804
20
Back to contentsWestern Cape
City/town Name Practice No
Cape Town Christiaan Barnard Memorial Hospital 5807778
Cape Town Kuilsriver Private Hospital 88978
Cape Town Mediclinic Cape Gate 366714
Cape Town Mediclinic Durbanville 5808766
Cape Town Mediclinic Durbanville Day Hospital 592781
Cape Town Mediclinic Louis Leipoldt 5806860
Cape Town Mediclinic Milnerton 5808669
Cape Town Melomed Bellville 5802881
Cape Town Melomed Gatesville 5808103
Cape Town N1 City Hospital 5808537
Cape Town Vincent Pallotti Hospital 5801443
George Mediclinic Geneva 5709059
George Mediclinic George 5807905
Hermanus Mediclinic Hermanus 5709091
Mossel Bay Bayview Hospital 5808790
Oudtshoorn Mediclinic Klein Karoo 5808928
Paarl Cure Day Clinics (St Stephen’s Paarl) 468541
Paarl Mediclinic Paarl 5808251
Plettenberg Bay Mediclinic Plettenberg Bay 283207
Somerset West Mediclinic Vergelegen 5808030
Stellenbosch Mediclinic Stellenbosch 5808405
Vredenburg West Coast Private Hospital 5808979
Worcester Mediclinic Worcester 5808006
21
Back to contentsEastern Cape
City/town Name Practice No
East London Life Beacon Bay Hospital 357669
East London St Dominic’s Hospital 5808294
East London St James Operating Theatres 5703816
Grahamstown Settlers Hospital 348090
Humansdorp Isivivana Private Hospital 168386
Port Alfred Port Alfred Hospital 328871
Port Elizabeth Greenacres Hospital 5807875
Port Elizabeth Medical Forum Theatre 7700873
Queenstown Life Queenstown Private Hospital 5709156
Uitenhage Cuyler Clinic 5808642
Free State
City/town Name Practice No
Bethlehem Bethlehem Medical Centre 7700792
Bloemfontein Citymed Theatre 7700938
Bloemfontein Horizon Eye Care Centre 225681
Bloemfontein Mediclinic Bloemfontein 5808154
Bloemfontein Universitas Private Hospital 131938
Kroonstad Kroon Hospital 5808383
Welkom Welkom Medical Centre 399337
Medihelp may change the information contained in this document from time to time and will publish any changes on our
website at www.medihelp.co.za
Hospitalisation video
To watch a video on hospitalisation or download a pamphlet on this topic, go to
www.medihelp.co.za
22
Back to contentsPrescribed minimum benefits (PMB)
What is prescribed minimum benefits (PMB)
PMB refer to a range of services and conditions that medical schemes must cover in terms of
the Medical Schemes Act 131 of 1998, and include –
• medical emergencies (in terms of the legal definition on page 24),
• 270 listed diagnosis and treatment pairs (DTPs), and
• 26 chronic diseases on the Chronic Diseases List (the CDL).
Prescribed minimum benefits (PMB) and Chronic Diseases List (CDL) conditions
1. Addison’s disease 14. Dysrhythmia
2. Asthma 15. Epilepsy
3. Bipolar mood disorder 16. Glaucoma
4. Bronchiectasis 17. Haemophilia A and B
5. Cardiac failure 18. Hyperlipidaemia
6. Cardiomyopathy 19. Hypertension
7. Chronic obstructive pulmonary diseasem(COPD) 20. Hypothyroidism
8. Chronic renal disease 21. Multiple sclerosis
9. Coronary artery disease 22. Parkinson’s disease
10. Crohn’s disease 23. Rheumatoid arthritis
11. Diabetes insipidus 24. Schizophrenia
12. Diabetes mellitus type 1 25. Systemic lupus erythematosus (SLE)
13. Diabetes mellitus type 2 26. Ulcerative colitis
Please note:
• Benefits for PMB services will only apply from the date on which Medihelp approves the
services. You will also receive a schedule of the approved services.
• Services will be funded from relevant available benefits first.
Measures which apply to all PMB-related services for consideration of benefits
Designated service Medicine
Pre-authorisation Protocols
providers (DSPs) formularies
Refer to the table Please study your Treatment A list of medicines
on page 33 for benefit summary guidelines as approved for the
details on how to to see which DSPs contained in treatment of
access benefits apply, to avoid the Regulations conditions
co-payments published under
the Medical
Schemes Act, 1998
23
Back to contentsAccessing benefits for your PMB conditions
Consultations and services Emergencies
Step 1: Register your illness Medical emergencies that meet the
Phone Medihelp’s PMB pre-authorisation definition as explained below also qualify
desk at 086 0100 678 and provide them for PMB, provided that a doctor motivates
with the relevant ICD-10 code (your these cases as such. Please have the
doctor will give you this code). Your illness emergency authorised as soon as possible
will then be registered for PMB – once you after the incident, but definitely on the
receive the authorisation schedule, you first workday after admission by phoning
will know exactly which services have been Medihelp at 086 0100 678.
approved.
An emergency is defined as follows in the
Step 2: Your benefit schedule Act: "Any sudden and unexpected onset of
The authorisation schedule sets out a health condition that requires immediate
the number of consultations and other medical or surgical treatment, where
treatments which have been approved as failure to provide such treatment would
part of your treatment protocol. Please result in serious impairment to bodily
study this schedule, because only the functions or serious dysfunction of a bodily
services listed on the schedule will qualify organ or part, or would place the person’s
for PMB. If your doctor wants to prescribe life in serious jeopardy." An emergency
other services not listed on your schedule, medical condition must be certified as
you will have to phone Medihelp at such by a medical practitioner.
086 0100 678 to apply for these services
to be authorised.
Hospitalisation
Medicine
All hospital admissions must be pre-
authorised by phoning Medihelp on
086 0200 678, or applying for pre-
To register your medicine for PMB, please
authorisation via the secured site for
complete the PMB and chronic medicine
members or the member app, or emailing
application form, which you can download
to hospitalauth@medihelp.co.za. If a non-
from the secured site for members (click
emergency admission is not authorised, a
on “Forms”) or request telephonically
20% co-payment on the benefit amount of
from our Customer Care Centre at
the hospital account will be payable by you.
086 0100 678. Certain illnesses on the
application form indicate entry criteria Emergency admissions must be
that must be met to qualify for PMB. authorised on the first workday after the
These may include test results and doctors’ admission. Members of the Dimension
motivations or reports. Please include Prime network options must be admitted
these where necessary to help finalise to a network hospital – see more on
your application. page 16.
Tip: Facility fees for emergency rooms do not qualify for benefits, and if the patient is not
admitted to hospital directly from the emergency room, PMB do not apply.
24
Back to contentsSpecialist networks for PMB services
Medihelp’s specialist networks support you with treatment for PMB conditions. By visiting
specialists who form part of these networks you can limit your out-of-pocket expenses, as
their tariffs are more in line with those of Medihelp.
It’s easy to locate your nearest network specialist:
Our website lists all our network hospitals and specialists.
Visit www.medihelp.co.za.
1 081 specialists covering
21 disciplines
Your PMB services will be paid in full, and other services at the Medihelp tariff
if you use a network specialist.
You will be responsible for the difference between the cost and
the Medihelp tariff if you don't use a network specialist.
Network specialists operate at network hospitals
Visit a network specialist because your benefit option has its own hospital network.
The network specialists are aligned with these hospitals, so it is important to ensure that
the specialist you choose operates at your network hospital.
Tip: To prevent any surprises on your specialists’ accounts, simply phone them before the
consultation or treatment and enquire about their fees. This way, you will know in advance
how much your co-payment (if any) will be. You can also negotiate a reduced fee with the
specialists or arrange payment terms.
To avoid co-payments on PMB services
1. Pre-authorise all PMB services – Make sure you pre-authorise the relevant
services where required, including hospital admissions. See the table on page 33
for more information.
2. Follow the protocols – Make sure your treating doctor or healthcare provider
follows the PMB treatment guidelines.
3. Use the MHRP co-payment calculator on the secured website for members.
4. Visit DSPs or network providers – visit www.medihelp.co.za to find a network
provider.
25
Back to contentsEmergency medical services
What is an emergency?
Any sudden and unexpected onset of a health condition that requires immediate medical or
surgical treatment, where failure to provide such treatment would result in serious impairment
to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s
life in serious jeopardy. An emergency medical condition must be certified as such by a medical
practitioner. Emergencies are also regarded as PMB conditions (see page 23-25 for more on PMB).
Please note: Have the emergency authorised as soon as possible after the incident, but
definitely on the first workday after admission by phoning Medihelp at 086 0100 678.
Emergency transport services
Who is our emergency transport services partner?
Netcare 911 is our partner in providing emergency medical services, including emergency
medical transport, emergency assistance and trauma counselling. Always phone
Netcare 911 on 082 911 for authorisation when you need emergency transport. You have
access to Netcare 911’s emergency services 24 hours a day, seven days a week.
To identify you as a member of Medihelp who may only make use of Netcare 911’s services,
we provide you with Netcare 911 stickers when you first join Medihelp. Affix this sticker to the
inside of your vehicle’s rear or side window. If you need new or additional stickers, phone us on
086 0100 678. You should also save Netcare 911’s telephone number on your cell phone so you
won’t have to remember the number in an emergency. You can also download the mySOS app
on your smartphone and link it to Netcare 911.
The mySOS app to assist you in case of an emergency
1
ARRIVE SAFELY
Download the mySOS MEDICAL EMERGENCY (when cycling, walking and driving)
Netcare 911 app
• Open the app • Enter your arrival time
2
• The app's GPS will send • The app tracks you
Indicate Medihelp on
your location to your • The app sends a map
the app as your provider emergency contacts and your location to
• The app will send an alert emergency contacts
3
Load your to Netcare 911's control if you are not on time
emergency contacts centre
Trauma counselling service
In addition to emergency transport services, Netcare 911 also offers all Medihelp members
free access to 24-hour trauma counselling on 082 911 which is provided by qualified medical
personnel. This service also gives you access to confidential and reliable healthcare advice.
26
Back to contentsMedicine benefits
Different types of medicine
Acute medicine Chronic medicine
Acute medicine is used to treat Chronic medicine is used to treat long-
short-term, acute diseases such as term conditions. It must prevent or treat a
sinusitis and diarrhoea. Self-medication serious illness, must sustain life, delay the
(acute medicine without a doctor’s disease’s progress, repair natural physiology
prescription) will also be funded from and must be the accepted treatment
the acute medicine benefit. according to approved guidelines.
PMB chronic medicine
PMB chronic medicine is used to treat any of the 26 conditions on the Chronic Diseases
List (CDL) if your condition complies with the entry criteria. See page 24 for more on how
Medihelp covers your PMB chronic medicine.
MobileMeds is the DSP for chronic PMB medicine
MobileMeds, Medihelp’s medicine order and delivery service, and a designated service
provider apply for PMB chronic medicine or a 60% co-payment will be payable. The
MobileMeds service allows you to order your registered chronic and even acute medicine
over the phone and have it delivered to the DSP delivery point or an address of your choice,
in which case a co-payment will apply. For more information about the MobileMeds
service, phone 086 0100 678.
Medihelp's medicine benefits
Original medicine Voluntary use of the
Generic medicine where no generic original medicine where
is available a generic is available
100% of the MMAP* 80% of the MT** 70% of the MMAP*
subject to benefits subject to benefits subject to benefits
available available available
* MMAP – The Maximum Medical Aid Price covers the cost of most generic equivalents of
the original medicine. It only applies to acute and non-PMB chronic medicine.
** MT – Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or
the single exit price.
27
Back to contentsBenefits of using generic medicine
Before a new medicine may be made available to the public, extensive research is necessary
to ensure it is effective and safe. This research costs millions, and pharmaceutical companies
register a patent on the medicine to recover some of these research and development costs.
After the patent rights have expired, other pharmaceutical companies may use the same
dosage form, active ingredient and strength, but with a different brand name. These
companies do not have to repeat all the research, making the generic so much cheaper. The
generic manufacturer has to prove that their medicine is as effective and of the same quality
as the original.
Generic medicine is exactly the same as the original medicine, but will cost you less. You
can ask your doctor or pharmacy for the generic equivalent of original medicine. You will also
receive an SMS from Medihelp indicating that a generic alternative is available when you
buy an original medicine item.
Medihelp Preferred Pharmacy Network
The majority of South African pharmacies form part of Medihelp’s Preferred Pharmacy
Network, which offers Medihelp members the most cost-effective professional fee on
prescribed medicine, helping you avoid additional co-payments on medicine.
Find your nearest preferred pharmacy by using Medihelp’s smartphone app (see
page 38) or visiting Medihelp’s website at www.medihelp.co.za.
How to reduce medicine co-payments
1 Visit a pharmacy in the Medihelp Preferred Pharmacy Network.
Use generic medicine – your generic medicine will be paid at 100% of the MMAP,
2 while an 80% or 70% benefit applies to original medicines. You will also have to
pay the difference in cost between the MMAP and the cost of the original product.
Use only authorised PMB medicine – Medihelp covers your authorised PMB
3 medicine at 100% of the Medihelp Reference Price.
Generic medicine video
To watch a video on generic medicine or download a pamphlet on this topic, go to the
secured site for members at www.medihelp.co.za
28
Back to contentsClaims submission
Make sure that your claims reach us on or before the last workday of the fourth calendar
month after the month in which the service was rendered. If the claim is rejected because
of omitted or incorrect information, you have 60 days from the date of rejection to
resubmit the claim.
Service rendered Month 1 Month 2 Month 3 Month 4
Last day
of submission
Who may submit your claims?
Most healthcare providers submit their claims directly to Medihelp and you need not submit
these again. However, if you have paid an account and want to claim, you can also submit
claims in any of the following ways:
• Use your Medihelp member app for smartphones by taking a photo of your claim and
submitting it in a few easy steps
• Email to claims@medihelp.co.za
• Post to Medihelp Claims Administration, PO Box 26004, Arcadia, 0007
Remember:
• You remain responsible to ensure Medihelp receives claims – even those submitted by
healthcare providers.
• Check your monthly statements regularly to keep track of your claims.
Healthcare services rendered abroad
If you or one of your dependants plans to travel abroad, please notify Medihelp of your plans.
Medihelp will send you a document explaining the process you should follow to ensure that
any claims for possible medical services rendered abroad are processed effectively.
Medical emergencies abroad
Medihelp members are covered for medical emergencies for a period of 90 days after their
departure from South Africa. Medihelp will pay the same tariff for the overseas medical
services as it would have paid for local services. This stipulation of 90 days’ coverage is for
emergencies only and does not apply in the following cases:
• If you are a resident of the RSA, Lesotho, Mozambique, Namibia, Swaziland or Botswana
and require medical services in these countries.
• If you are stationed abroad by your employer.
• If you are studying or working abroad on the instruction of your employer. Please submit
a letter from your employer to Medihelp in which it is confirmed that you are working or
studying abroad. The letter must include the expected departure and return dates.
29
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