Understand the terms before you call the scheme

PMBs are a set of minimum benefits that every registered medical scheme in South Africa must cover by law, regardless of the plan you are on.

PMBs cover three broad areas: - A defined list of emergency medical conditions. - 271 Diagnosis and Treatment Pairs (specific conditions matched to specific treatments). - 26 Chronic Disease List conditions.

Important things members get wrong: - PMB cover depends on your diagnosis, the treatment pathway, the rules, and your scheme's processes — it is not automatic just because something feels serious. - ICD-10 codes matter. The diagnosis code your doctor uses affects whether a claim is assessed as a PMB. - Schemes may require you to use a Designated Service Provider (DSP) for PMB cover. Using a non-DSP can create a co-payment, except in a genuine emergency. - PMB status is not something this tool (or you) can self-declare. It must be confirmed by your doctor and your scheme. - Scheme documents may describe certain PMB categories differently. Confirm the wording, rules, and process that apply to your specific scheme and plan.

What to ask: - Ask your doctor: "Could this condition and treatment qualify as a PMB? What ICD-10 code are you using?" - Ask your scheme: "Is this being assessed as a PMB? Do I need to use a DSP? What do you need from me?"

A Designated Service Provider (DSP) is a healthcare provider (doctor, hospital, or pharmacy) that your scheme has chosen as the first-choice provider for certain benefits — especially PMBs.

A network is a broader group of providers the scheme has contracted with, often at agreed rates.

Why schemes use them: - To control costs by agreeing rates in advance. - In exchange, you usually pay less (or nothing) out of pocket when you use them.

How co-payments arise: - If you voluntarily use a provider outside the DSP/network, the scheme may only pay up to a certain rate and you cover the difference (a co-payment). - In a genuine emergency, you should not be penalised for using the nearest facility — confirm this with your scheme afterwards.

What to ask before using a provider: - "Is this provider in my plan's network / a DSP for this benefit?" - "If not, what co-payment would I face?" - "Is there a DSP I should use instead to avoid extra costs?"

This tool does not recommend specific providers.

An ICD-10 code is a standardised code that describes a diagnosis. Every medical claim carries one (or more).

Why they matter to you: - The ICD-10 code is a major factor in how your scheme assesses a claim — including whether it is treated as a PMB or a chronic benefit. - A missing or incorrect code is a common reason claims are rejected or paid from the wrong benefit.

What to do: - Ask your doctor or provider: "What ICD-10 code(s) are on my account?" - If a claim is rejected, check whether the code is correct and complete before anything else. - Keep the codes with your records.

Pre-authorisation is approval you get from your scheme before certain planned care — typically hospital admissions, scans (like MRI/CT), and some procedures.

Why it matters: - If authorisation is required and you skip it, the claim can be rejected or reduced, even if the care itself would have been covered. - Authorisation is not the same as a guarantee of full payment — it confirms the scheme expects the care, but co-payments and limits can still apply.

Before planned care, ask your scheme: - "Does this need pre-authorisation?" - "What information do you need (ICD-10 code, procedure codes, quote)?" - "Are there any co-payments?" - "Is the hospital/facility in-network?"

Always keep the authorisation number.

In an emergency, get care first and sort authorisation out afterwards.

If you are diagnosed with an ongoing condition, you may be able to register for chronic medicine benefits so your medication is funded from a chronic benefit rather than your day-to-day savings.

The general process: 1. Your doctor confirms the diagnosis and the ICD-10 code. 2. You (or your doctor) submit a chronic application to the scheme. 3. The scheme approves (or declines) chronic cover, often for a set period. 4. The medication may need to be on the scheme formulary (approved list) and collected from a DSP pharmacy to avoid co-payments.

What to confirm: - "Could my condition qualify for chronic / PMB cover?" (doctor + scheme) - "Is my medication on the formulary?" - "Do I need to use a specific DSP pharmacy?" - "What follow-up tests and consultations are covered?"

Approval must come from the scheme — this tool cannot approve cover.

A co-payment is an amount you pay out of your own pocket, on top of what the scheme pays.

Common reasons co-payments arise: - Using a provider outside the network / DSP. - Certain procedures the scheme flags as needing a fixed co-payment. - A provider charging above the scheme rate (private rate vs medical aid rate). - Benefit limits being reached.

How to reduce surprises: - Before planned care, ask: "Will there be a co-payment, and how much?" - Ask the provider: "Do you charge the medical aid rate or a private rate?" - Get a written quote with codes so the scheme can confirm in advance.

A rejected claim is not always the end of the road. Many rejections come down to missing information, wrong codes, or a step that was skipped.

First steps: - Get the written reason for the rejection from your scheme. - Check the ICD-10 and procedure codes with your provider — errors here are common. - Check whether authorisation was needed and obtained. - Check whether a network / DSP rule applied.

If you think the rejection is wrong: - Ask the provider to correct and resubmit if it was a coding or admin error. - Follow your scheme's internal dispute process first — request it in writing. - Only after the internal process should external escalation be considered.

What to avoid: - Making accusations without the written reasons in hand. - Assuming the outcome — claim outcomes cannot be guaranteed.

This tool helps you organise the right questions and documents. It does not predict or guarantee the outcome.