Pulse1 benefit option authorisation for specialist and out-of-network visits
Specialist visits
What specialist visit benefits are available on the Pulse1 Scheme option?
Every family has a maximum of three (3) specialist visits per year. The total cost for the visit, including tests and medicine has a maximum monetary (Rand) value. For more information see the benefits section. Any amount exceeding this limit will be for the member’s own account. To confirm the maximum amount available for the specialist visit, contact the Client Service Department:
Visits or services from a number of specialists do not qualify for benefits. These include radiologists, pathologists, dentists and ophthalmologists. Specialist referrals will only be considered for authorisation where the referral is requested by a network general practitioner from the contracted DSP.
Who can obtain a pre–authorisation number?
The member or dependant, a family member with the necessary information or the treating DSP or network provider can call to obtain an authorisation number. The final responsibility to ensure that an authorisation has been granted remains with the member.
Which information will be required to get an authorisation number?
- Membership number
- Name and date of birth of member or beneficiary attending the specialist
- Date of specialist visit
- Name and practice number of the referring DSP or network provider
- The clinical reason for the specialist visit
- The diagnosis or ICD–10 code/s
- The type of specialist and practice number
What must the member or patient do with the authorisation number?
- The member/dependant should give the authorisation number to the staff at the practice of the specialist.
- The authorisation number must appear on all claims submitted by the specialist practice to the Scheme for payment.
- The authorisation number may not be used for any other event or on another date as the one specified. Please note that the authorisation number is only valid for the specified day and is only valid for one visit. If the specialist wants to refer the patient to another specialist, a new authorisation must be obtained for the second specialist.
- If the fees charged by the specialist are higher than the maximum paid by the Scheme, the member will be responsible for paying the difference. Please check with the specialist’s staff what fees will be charged.
- All accounts for specialist visits must be submitted within four months of the service date
Can authorisation be denied?
An authorisation number will not be given under the following circumstances:
- The member/dependant has a waiting period related to the referral.
- The member/dependant does not have benefits for the specialist requested e.g. plastic surgery.
- Benefit limits for specialist visits have been reached for the year.
- The member/dependant wants to go for to the specialist for an existing illness condition that hasn’t been disclosed on the application form (non–disclosure).
- The member/dependant was not referred by a DSP or network provider.
- The clinical reason or motivation for referral does not comply with the Scheme funding guidelines for specialist referral.
- The visit already took place and an authorisation is only requested after the service was rendered.
Where can one get more information on specialist visits and related queries?
Out–of–network visits
What out–of–network visit benefits are available on the Pulse1 Scheme option?
Every family qualifies for two (2) out–of–network visits per year with another general practitioner that must be pre–authorised by Bestmed in order to be reimbursed. Visits will only be considered for funding where members are in an area regarded as ‘out of network’ (this is 50 km or more from the nearest network service point) or when the service point is closed. Each visit has a maximum amount that will be reimbursed. The Authorisation Centre will have more information on the available amount.
Who can obtain a pre–authorisation number?
The member or dependant, a family member with the necessary information, the personnel at the facility or general practitioner (GP) being consulted can call to obtain an authorisation number. The final responsibility to ensure that an authorisation has been granted remains with the member.
What information will be required to get an authorisation number?
- Membership number
- Name and date of birth of member or beneficiary visiting the doctor
- Date and time of out–of–network visit
- Name and practice number of out–of–network provider
- The clinical reason for the visit
- The diagnosis or ICD–10 code/s
What must the member or patient do with the authorisation number?
- The member/dependant should provide the authorisation number to the staff at the practice of the general practitioner they are visiting.
- The authorisation number must appear on all claims submitted by the general practitioner’s practice to the Scheme for payment.
- The authorisation number may not be used for any other event or on another date as the one specified. Please note that the authorisation number is only valid for the specified day and is only valid for one visit. If the GP wants to refer the patient to a specialist, a specialist authorisation must first be obtained.
- If the fees charged by the out–of–network GP are higher than the maximum paid by the Scheme, the member will be responsible for paying the difference. Please confirm with the doctors’ staff what fees will be charged.
- All accounts for out–of–network visits must be submitted within four months of the service date.
Can authorisation be denied?
Authorisation will not be granted in the following circumstances:
- The member/dependant has a waiting period related to the visit.
- Benefit limits for out–of–network visits have been reached for the year.
- The DSP or network provider is close by or is available (office hours) at the time the out–of–network visit is requested or completed.
- The visit has already occurred and an authorisation is only requested after the service was rendered.
Where can one get more information on out–of–network visits and related queries?
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