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What is pre–authorisation?

This is the process whereby patients obtain an authorisation number from the Scheme before they are admitted to hospital.

This number is crucial because the Scheme will only cover events where a pre–authorisation number has been obtained. Unauthorised admissions are excluded from benefits. During the authorisation process the member’s active status is verified and the admission is approved for funding.

A dedicated telephone number, printed on the membership card, gives a caller access to the authorisation Centre where the authorisation numbers are obtained (see authorisation contact details below).

Why is pre–authorisation necessary?

Bestmed scheme benefits cover admissions and hospitals based on services and procedures as set out in the registered rules, benefits and funding guidelines. The associated guidelines and protocols are linked to the various diagnoses (ICD– 10 codes) and procedure codes (CPT 4 codes). These reflect the amount and extent of services covered. It is possible that members or providers prefer procedures in a way that is different or more expensive than the funding guideline of the Scheme. The pre–authorisation process guides all the parties as to what is fully covered and what not. Only services that are within the funding guidelines of the Scheme are covered. It always remains the prerogative of members and providers to obtain and render services as they see fit, however, Bestmed only covers services as set out in their funding guidelines and protocols. The pre–authorisation process helps to ensure that members and providers are aware of what will be paid by the Scheme. The services, the number of days covered in hospital and details related to Scheme cover pertaining to the admission are all linked to the authorisation number. Only these specified items will be considered for funding when claims are processed.

Which hospital based services must be pre–authorised?

All admissions, even day procedures in a hospital or day clinic, must be pre–authorised. Certain services rendered during hospitalisation must be pre–authorised in their own right such as scans and procedures. All admissions that are planned ahead of time, also referred to as ‘elective procedures’, must preferably be authorised at least 14 days before the admission date. In cases of clinical urgency or an emergency, an authorisation must be obtained as soon as the admission takes place. Where admissions take place on weekends of after hours, authorisation must be obtained on the first business day after the admission date.

Who can obtain a pre–authorisation number?

The member, dependant,or a family member with the necessary information, and the hospital staff or treating provider can call in to obtain an authorisation number.

How does the authorisation process work?

Dial the number for the authorisation centre and have the following information ready:

• Membership number as printed on the membership card
• Name of member or beneficiary (dependant) and date of birth
• Date of admission
• Date of the operation (if applicable)
• Name of the treating doctor and the practice number
• Name of the hospital and the practice number
• The reason for the admission to hospital (for example, tonsillectomy, chest pain or stroke)
• The ICD–10 code/s – these are codes that specify the specific diagnosis and can be obtained from the treating doctor
• If admitted for an operation, the procedure codes (tariff codes) the doctor intends using

In certain cases the authorisation agent may ask for additional information that is required before an authorisation can be generated. The authorisation number must be provided to the hospital and providers rendering inpatient services and must appear on all claims as claims cannot be processed and paid without this number. An authorisation number can only be used once for the specific event it is linked to and for the services specified during the authorisation.

Can the Scheme refuse to give an authorisation number/deny authorisation?

There are circumstances where an authorisation number may not be given. If a member is not an active fully paid up member or has a waiting period, an authorisation number will not be given. The same will happen if the requested services are related to an exclusion linked to the patients’ membership. In some cases the services may be excluded from benefits under the Scheme rules or the patient may not have benefits for the requested admission. This can happen where limits or sub–limits have been depleted, or where the Scheme option the patient belongs to does not cover the services applied for. Where an admission or procedure is requested in the period after joining the Scheme and where the services requested could be related to an underlying or chronic condition, the Scheme will need to verify if such a condition was mentioned on the application form and if such a condition can be regarded as a pre–existing condition. During this verification process an authorisation number will not be given. The possibility also exists that the services proposed by the member and/or provider do not conform to the funding guidelines of the Scheme in which case authorisation can’t be granted.

What is a designated service provider (DSP)?

Bestmed may from time to time contract providers or groups of providers to render specified services to its members. Such contracted providers are called ‘designated service providers’(DSPs). The Scheme rules and benefits stipulate the services rendered by DSPs. In some cases services are only funded at a DSP and the Scheme will not fund the same services rendered by other providers.

Which services are excluded from benefits during a hospital admission?

Certain medicines, such as certain antibiotics are not routinely covered by the Scheme. The list of medicines and other products not covered by the scheme is communicated to hospital groups on a regular basis. Some implants or prosthesis are not covered, as are services outside the parameters of the Scheme funding guideline. Services specified as “Exclusions” under the Scheme rules will not be covered.

What are the contact details of the authorisation centre for hospitalisation?