Home > Benefits > Prescribed Minimum Benefits (PMB) cover

What is PMB’s?

• Prescribed Minimum Benefits (PMB’s) are conditions that are funded from the Scheme’s risk pool, based on the stipulations in the Medical Schemes Act and the Regulations of the Act. Therefore a structured PMB process that meets legislative requirements as well as supports cost containment were implemented for Bestmed members. 

How does one apply for PMB benefits?

If a member wants to apply for a specific service to be evaluated and approved from the PMB risk pool, the following must be kept in mind:Only qualifying PMB ICD–10 codes will be considered for PMB benefits.

• PMB’s also serves as an initiate and awareness campaign to ensure members are educated on their responsibility with regards to discussing Scheme rates with their providers. Part of this initiative is to inform members and to ensure that the provider is made aware of the schemes rate and discusses their rates with the member before services are rendered; where applicable. This process will lead to better informed members who understand upfront what their financial obligations will be with regards to the services being rendered; and afford the member the opportunity to negotiate or seek a more cost effective alternative.
• The Bestmed PMB application form has to be completed by the treating provider as well as member for this request to be considered for PMB benefits.The PMB application request form is available and can be requested by the members and or providers by contacting the call centre. This PMB application request form must be signed by both the member and provider and if a dispute arises can be requested by the scheme. 
• PMB benefits are authorised by means of retrospective application. Decision making is based on the  support of or made in accordance with the relevant treatment algorithms of the PMB regulations, Scheme protocols, Scheme rules, formularies and other managed care initiatives.
• Once a decision is made by the PMB department both the member and or provider will be informed of the outcome of the PMB application request via email and or telephone.
• Any PMB applications and or related PMB enquiries can be submitted by contacting Bestmed’s client service contact centre at 086 000 2378 or service@bestmed.co.za.
• Completed application forms can also be e-mailed to pmb@bestmed.co.za , faxed to (012) 472 6760 or posted to P.O Box 2297, Pretoria, 0001.

Frequently Asked PMB Related Questions:

1. How do I know that my application has been approved?
   For any application received, an e-mail will be sent to the practice as well as the member informing them of the decision that has been made by the PMB department.
   
   
2. What happens once a beneficiary’s application is approved?
   If an application has been approved for retrospective services, Bestmed will arrange for the claim/s to be processed from the PMB benefit.
   All corrections on claims will be able to be viewed on the e-mailed and/or posted claims statement.
   
   
3. What happens if an account was short paid and the account has now been approved as PMB?
   Bestmed will arrange for the short paid amount to be paid into the member’s bank account so that the member can settle the account directly with the practice.
   
   
4. If I have GAP Cover, will they cover the shortfall on all my in-hospital accounts?
   GAP Cover may cover for the shortfall of in-hospital accounts that are not valid PMB cases.
   If the hospitalisation was for a valid PMB, then the practice or member needs to apply directly to Bestmed to possibly approve the shortfall as PMB.
   
   
5. Where can the PMB application form be obtained?
   The form is available from Bestmed’s client service contact centre at 086 000 2378, by e-mailing a request to pmb@bestmed.co.za or sending a faxed request to (012) 472 6760.