Approving Better Healthcare

Having a medical procedure done can be stressful – even more so if you have to stay in hospital for a few days. To make matters worse there’s the issue of what your medical aid will cover and what it won’t.

A pre-authorisation process might seem like an added stress, but it’s necessary to protect you as our member and to offer you peace of mind so that you can concentrate on recovering. 

Why is pre-authorisation important?

Whether you’re on Pace, Pulse or Beat, all our medical aid plans include hospital benefits. However, each plan has different hospital benefits available to it and the level of cover you have in hospital depends on the plan you’ve chosen. The pre-authorisation process allows us to:

  • Prepare you for your healthcare event so we can structure upcoming payments and manage protocols if necessary.
  • Inform you about the available benefits for the healthcare service you are about to purchase.
  • Help you understand what will and what won’t be paid and, if necessary, to assist you in negotiating rates with your provider.
  • Ensure that only clinically necessary and cost-effective services are funded.

It’s important to note that, even if you have received pre-authorisation, some medicines, implants, protheses and services may fall outside our Scheme Funding Guidelines and will not be covered while you are in hospital. 

When do you need pre-authorisation?

All procedures planned ahead of time must be pre-authorised at least 14 days before the date of admission. This includes a hospital stay, a procedure performed in a doctor’s room, the purchase of medical appliances or other elective services.

Emergencies must be pre-authorised during admission into hospital or on the first working day after a weekend or public holiday.

Who can request pre-authorisation?

You, your family or a dependant with the necessary information can contact us

to get a pre-authorisation number. In some cases, the hospital staff or treating provider may get an authorisation number on your behalf.

Information needed for your pre-authorisation request:

  • Your membership number and the details of the member who the request is for.
  • The date you are going into hospital and the date of the treatment or procedure.
  • The name of the doctor who will be treating the member and their practice number.
  • The name of the hospital where you will receive treatment and its practice number.
  • The reason for admission to hospital.
  • The relevant procedure and ICD-10 codes for the treatment (ask your doctor for these).

Please note: Our authorisation agents may ask for more information before we can give you a pre-authorisation code.

Pre-authorisation requests may be declined if:

  • The procedure or treatment isn’t covered by your plan as specified in the Scheme Rules.
  • The procedure or treatment isn’t in line with the clinical and medical treatment standards for your condition.
  • The information required for pre-authorisation isn’t included.
  • Your Bestmed membership is inactive or a waiting period has been applied.

We have a dedicated team to assist you with your authorisation and to answer all your questions.

Call the authorisation team on 0800 220 106 or email authorisations@bestmed.co.za

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