April 2017 necesse network 2017

Transcription

1 April 2017 necesse network 2017

2 contents 1 why medihelp is the right choice 2 a summary of your benefit option 3 accessing necesse benefits 4 preventive care 5 benefits 5 Day-to-day benefits: Services rendered by a Necesse network GP 5 Pregnancy benefits 6 Specialist care 7 Medicine prescribed by a Necesse network doctor 8 Standard radiology and pathology 9 Eye tests, spectacles or contact lenses 9 Physiotherapy and occupational therapy 10 Oxygen (out of hospital) 10 Basic dental services 11 core benefits 11 Trauma recovery 12 Prescribed minimum benefits (PMB) 12 Oncology (PMB only) 13 HIV/Aids (PMB only) 13 Other services covered as PMB services 15 Emergencies and out-of-network consultations 15 Emergency transport 16 Hospitalisation 19 Sub-acute and private nursing services as an alternative to hospitalisation

3 19 supporting information 19 Cardio risk management programme 20 Finding network providers on your cell phone 21 Specialist network 22 Necesse hospital network 29 Important contact numbers and pre-authorisation 31 Explanation of terms 34 General exclusions 37 Dental exclusions 39 Medihelp s banking details 40 Proof of income 43 contact us This guide has been specially compiled so you will know exactly how to use your benefits. There are certain choices you have to make and processes you need to follow which are especially important within a network option such as Necesse. If you follow these, you will be able to use your benefits effectively and sensibly, and you'll know how and where to access healthcare services when you need them. The guide contains all the numbers and contact details that you may need. You can also phone us on , visit Medihelp s website at and sign in to Medihelp Online the secured site for members or download the member app where you will find even more information. This guide provides a summary of the Necesse benefit option. In the case of a dispute, the registered Rules of Medihelp will apply, subject to approval by the Registrar of Medical Schemes. If a beneficiary joins during the course of a financial year, the benefits are calculated pro rata according to the remaining number of months per year.

4 why contents medihelp is the right choice 1it s all about you Everyone is unique, but the need to secure our wellness is something we all share. That is why Medihelp has individualised our approach to fulfil your healthcare needs Consistent service and engagement on online and offline service platforms Videos A member application with an electronic membership card to explain complex processes A dedicated call centre A secured website to change and view your Medihelp profile & benefits Multiple engagement opportunities through social and digital channels BLOG 2a sound healthcare investment Medihelp ticks all the boxes of a sound investment years experience in the industry and a solid reputation 111 A solvency level that has been consistently above the industry requirement AA- rating for our claims-paying ability, awarded by Global Credit Rating One of the largest open medical schemes in the industry Preventive care Health conscious 3individualised value Get active A menu of separate, additional preventive care benefits An individualised, free wellness programme provides relevant support during every life stage Join Medihelp MultiSport for running, walking and cycling 1

5 a summary of your benefit option An income-based network option with hospital and day-to-day benefits, and access to quality network providers. This option is the ideal healthcare solution in the corporate environment and for full-time tertiary students. Essential cover for chronic illnesses on the Chronic Diseases List and 270 listed prescribed minimum benefits Comprehensive hospital cover in the Necesse hospital network Cover for medical emergencies Cover for specialised radiology Cover for preventive care health assessment tests Monthly contributions Children pay child dependant rates until they are 21 years old Gross monthly income Full-time students R0 R400 R401 R5 000 R5 001 R7 000 R7 001 R R and more Principal member R438 R1 404 R1 464 R1 656 R1 932 Dependant R438 R1 110 R1 170 R1 290 R1 506 Child dependant <21 years R438 R600 R660 R726 R834 The monthly contributions do not take any employer subsidy into account. Older children pay child dependant rates until they are 21 years old. 2

6 accessing necesse benefits Network GP consultations Visit your Necesse network GP S/he will refer you to other doctors if needed Every beneficiary has 9 consultations per year Find the Necesse GP network list on our website at Medicine Specialists and other referrals Network hospitals Acute medicine Get formulary medicine from Your dispensing Necesse network GP; or A network pharmacy on your Necesse network GP's prescription Pre-authorisation PMB chronic medicine Your Necesse network GP will complete an application form to register your PMB chronic medicine Once approved, get the medicine from a Medihelp network pharmacy or network courier pharmacy, or order from MobileMeds Pre-authorisation Your Necesse network GP will refer you to a specialist or physiotherapist S/he will complete a referral form to authorise the specialist s consultation and follow-up consultation, or you can phone and request a reference number for the specialist consultation Use the Necesse specialist network for PMB services to reduce out-of-pocket expenses Find the specialist network on our website at Emergency services Phone Netcare 911 on for emergency transport services in the RSA Pre-authorisation Your Necesse network GP or the specialist to whom s/he referred you can admit you to a Necesse network hospital Authorise all admissions well in advance A 35% co-payment applies to voluntary out-of-network and a 20% co-payment to unauthorised admissions Register emergency admissions on the first workday after the admission Find the Necesse hospital network list on our website at Register emergencies X-rays and blood tests Your Necesse network GP may refer you for basic X-rays or blood tests according to the list of available tests. Blood tests must be done only by Lancet or PathCare laboratories. What is an emergency? A sudden, unexpected health condition requiring immediate medical or surgical treatment (If you re not treated, it will cause serious damage to organs, bodily functions or death) Emergency or out-of-network consultations If you have to visit a non-network GP in an emergency, you will have to pay the account first, and then claim from the available out-of-network benefit from Medihelp. 3 GP General practitioner PMB Prescribed minimum benefits

7 preventive care Medihelp s preventive care benefits are designed to enable you to identify and help prevent potential health problems. Preventive care Health tests Blood glucose s Item codes More information Pathology: 4057 Cholesterol Pathology: 4027 HIV Pap smear Mammogram Prostate test (PSA level) 40 years + Bone mineral density test (BMD) _ 40 years + _ 50 years + One per beneficiary per year Pathology: 3932/4614 Pathology: 4566 Radiology: 3605/39175/ 34100/34101 Pathology: 4519 Radiology: 3604/50120 A Necesse network GP must request the services s are paid from the available day-to-day benefits Immunisation Flu vaccine Tetanus vaccine s One per beneficiary per year More information A Necesse network GP must request the services s are paid from available day-to-day benefits Back treatment programme One Document-Based Care (DBC) back treatment programme per beneficiary per year at a DBC facility (subject to protocols and pre-authorisation). HealthPrint wellness programme HealthPrint is an online wellness programme that supports you with relevant health information through every life stage. You can also: View, update and share your health information and results of your health assessment via the site Add your activity tracker and view your performance Join Medihelp MultiSport, receive sports gear at a discounted price and participate as part of the Medihelp team in supported events Join lifestage-specific programmes such as the pregnancy and baby programme and receive added value. GP General practitioner 4

8 benefits day-to-day benefits Services rendered by a Necesse network GP Always visit a doctor who is part of the Necesse GP network. Visit the Medihelp website at dial *120*6364# on your cell phone or use the Medihelp member app for a list of network doctors near you. Every family member has nine consultations available per year. Description GP SERVICES WITHIN THE NECESSE NETWORK Consultations Medical and surgical services as well as anaesthetic Material and discretionary medicine used during services Pregnancy benefits 9 consultations per beneficiary per year (shared with pregnancy GP consultations) Pre- and post-natal care services must be provided by your Necesse network GP. Midwife services must be rendered by a registered practising nurse and are subject to preauthorisation and treatment guidelines (protocols). Sonars are subject to referral by a Necesse network GP, or a specialist on referral by your Necesse network GP. Patients receive two additional consultations at a gynaecologist. See page 17 for hospital benefits for confinement (childbirth). Description PREGNANCY Pre- and post-natal care provided by a Necesse network GP Midwife services by a registered nursing practitioner for pre- and post-natal care and subject to preauthorisation Gynaecologist services Subject to referral by a Necesse network GP and pre-authorisation 9 consultations per beneficiary per year (shared with other GP consultations) Unlimited 20% co-payment if not pre-authorised 2 consultations per beneficiary in addition to the specialist limit 20% co-payment if not on referral or not pre-authorised Sonars (2D) Two 2D sonars per beneficiary per year 5 MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price Necesse network GP a general practitioner in the Necesse network

9 Specialist care You may only visit a specialist if you are referred by your Necesse network GP. If not, a 20% co-payment on the consultation will apply. Phone or hospitalauth@medihelp.co.za to obtain a specialist referral. For your convenience, Medihelp has established a specialist network read more about this network on page 21. Limits apply the specialist consultation and relevant procedures, acute medicine, standard radiology and pathology which the specialist requests are paid from the benefit for specialist care. No benefits will be paid if you were not referred by your Necesse network doctor in case of radiology services, and co-payments will apply to pathology services. The specialist s consultation must be pre-authorised by Medihelp and you must visit the specialist within the authorised period. The authorisation includes a follow-up consultation. If the specialist consultation has not been approved or services are rendered outside the approved period, benefits will not be paid. If the services cannot be rendered within the approved period, you must contact Medihelp again to authorise these services. It is preferable to visit a specialist who practises at a network hospital, in case you need to be admitted to hospital. All acute medicine prescribed by a specialist must be obtained within the authorised period from a pharmacy in the Medihelp Preferred Pharmacy Network, or administered and dispensed by a specialist. Only approved PMB chronic medicine used for the treatment of PMB/CDL conditions will qualify for chronic medicine benefits, if prescribed by a specialist on referral by your Necesse network GP. Pathology services requested by a specialist must be rendered by either Lancet (PR ) or PathCare (PR Drs Dietrich, Voigt, Mia & Partners) to avoid a co-payment. Description SPECIALIST CARE Subject to referral by a Necesse network GP and pre-authorisation, which includes one follow-up consultation: Specialist consultations Surgical and non-surgical procedures Diagnostic endoscopic procedures performed in the specialist s rooms Standard radiology and pathology (Lancet/PathCare) requested by a specialist Interventional procedures performed by radiologists Acute medicine administered and dispensed by a specialist Acute medicine prescribed by a specialist and obtained from a network pharmacy M = R2 800 M + = R % co-payment if not referred by a Necesse network GP CDL Chronic Diseases List Necesse network GP a general practitioner in the Necesse network PMB Prescribed minimum benefits M Member MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 6

10 Description Authorised PMB chronic medicine prescribed by a specialist on referral by a Necesse network GP is subject to pre-authorisation and must be obtained from a network pharmacy Medicine prescribed by a Necesse network doctor Acute medicine prescribed by a Necesse network doctor 100% of the Necesse PMB formulary Co-payments may apply in case of voluntary non-network pharmacy use, deviation from the formulary and if not referred by a Necesse network GP Acute medicine must be prescribed by your Necesse network GP or dispensed by a dispensing Necesse network GP. Medicine may only be obtained from your dispensing network GP or on prescription at a pharmacy in the Medihelp Preferred Pharmacy Network. Visit Medihelp s website at for a list of network pharmacies, phone Medihelp on , dial *120*6364# on your cell phone, or use Medihelp s member app to locate your nearest network pharmacy. Only medicines on the Necesse acute medicine formulary qualify for benefits. If your Necesse network doctor dispenses medicine, he/she must not give you a prescription to hand in at your network pharmacy these medicine claims will not qualify for benefits. Description Acute medicine Dispensed by a dispensing Necesse network GP (included in the consultation fee) Only formulary medicine obtained from a network pharmacy if prescribed by a Necesse network GP or Denis network dentist 100% of the MMAP according to the Necesse acute medicine/dental formularies Self-medication (over-the-counter medicine) Self-medication may be obtained without a prescription. Self-medication can only be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Visit Medihelp s website at for a list of network pharmacies, phone Medihelp on , dial *120*6364# on your cell phone, or use Medihelp s member app to locate your nearest network pharmacy. Limits apply. Description Self-medication obtained from a network pharmacy 100% of the MMAP R100 per event R260 per beneficiary per year 7 Necesse network GP a general practitioner in the Necesse network MMAP Maximum Medical Aid Price PMB Prescribed minimum benefits MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

11 Authorised PMB chronic medicine Chronic medicine for PMB/CDL conditions must be prescribed by your Necesse network GP. Chronic medicine for PMB/CDL conditions may only be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Visit Medihelp s website at for a list of network pharmacies, phone Medihelp on , dial *120*6364# on your cell phone, or use Medihelp s member app for smartphones to locate your nearest network pharmacy. You can also phone MobileMeds on to order authorised PMB chronic medicine and have it delivered. All chronic medicines for PMB/CDL conditions must first be approved by Medihelp, and are subject to registration protocols. Description Authorised PMB chronic medicine obtained from a network pharmacy Subject to pre-authorisation, protocols and formulary 100% of the MHRP according to the Necesse PMB chronic medicine formulary Unlimited Standard radiology and pathology Standard radiology services must be requested by your Necesse network GP and pathology by your network GP or a medical doctor. Blood tests must be performed by either Lancet (PR ) or PathCare (PR Drs Dietrich, Voigt, Mia & Partners). s will only be granted for a list of approved standard radiology and pathology services (Scheme-approved codes). Description STANDARD RADIOLOGY (X-RAYS) Subject to Scheme-approved codes and referred by a Necesse network GP Black and white X-rays and soft-tissue ultrasound scans only as per the Scheme s clinical protocols PATHOLOGY Subject to a list of pathology codes and tests only, done by Lancet/PathCare on request of a medical doctor Co-payments apply if services are not rendered by Lancet/PathCare CDL Chronic Diseases List Necesse network GP a general practitioner in the Necesse network PMB Prescribed minimum benefits MHRP Medihelp Reference Price MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 8

12 Eye tests, spectacles or contact lenses PPN must first approve the optical services. s are available per beneficiary per 24-month cycle. Limits apply on frames/lense enhancements and contact lenses. Description OPTOMETRY s are subject to pre-authorisation by PPN Optometric examinations 1 composite consultation, including refraction test, tonometry and visual field test 1 composite examination per beneficiary per 24-month cycle Spectacles or contact lenses s are limited to either spectacles or contact lenses: Spectacles Frames and/or lens enhancements R200 per beneficiary per 24-month cycle Lenses (one pair of standard clear Aquity lenses) Single vision, bifocal or multifocal (paid at the cost of bifocal lenses) lenses per beneficiary per 24-month cycle Contact lenses R395 per beneficiary per 24-month cycle Physiotherapy and occupational therapy These services must be requested by your Necesse network GP. Limits apply. Should a specialist request these services, there must be a referral for the specialist visit, and services will be paid out of the physiotherapy and occupational therapy benefit. Description PHYSIOTHERAPY AND OCCUPATIONAL THERAPY Out of hospital Must be requested by a Necesse network GP M = R1 800 per year M+ = R2 800 per year Necesse network GP a general practitioner in the Necesse network M Member MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price PPN Preferred Provider Negotiators 9

13 Oxygen (out of hospital) Subject to clinical protocols and pre-authorisation. Description OXYGEN Out of hospital Prescribed by a medical doctor and subject to pre-authorisation and clinical protocols 20% co-payment if not pre-authorised Basic dental services You must obtain all dental services from a dentist in the Dental Information Systems (Denis) network. Visit or dial *120*6364# on your cell phone or phone Denis on for a list of Denis network dentists near you. You can also use Medihelp s member app to locate a Denis network dentist near you. s are only provided for basic conservative dental services that meet specific clinical treatment guidelines (protocols). Dental services that are excluded from benefits are listed on page 37. All benefits are subject to Denis protocols and managed care interventions. Your Denis network dentist may only prescribe medicine on the Necesse dental formulary. Description DENTAL SERVICES Subject to Denis managed care protocols and services rendered by a Denis network dentist Conservative services Routine check-ups 1 per beneficiary per year Fillings (X-rays and treatment plans may be requested for multiple fillings) Oral hygiene Only children younger than 16 years 1 fluoride treatment per beneficiary per year for children from 5 16 years Fissure sealants Tooth extractions 4 fillings per beneficiary, 1 filling per tooth in 365 days Amalgam fillings (item codes 8341/8342/8343/8344) and resin restorations in anterior teeth (item codes 8351/8352/8353/8354) 1 polish (item code 8155) or 1 scale and polish (item code 8159) treatment per year Root canal treatment in the dentist s chair 2 teeth per beneficiary per year Necesse network GP a general practitioner in the Necesse network MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 10

14 Description Plastic dentures Including associated laboratory costs 80% of the MT 1 set (upper and lower jaw) per family (21 years and older) in a 2-year period Laughing gas (in the dentist s chair) Dental procedures under conscious sedation in the dentist s chair (sedation cost) Subject to pre-authorisation X-rays Intra-oral Extensive dental treatment only 20% co-payment if not pre-authorised 4 per beneficiary per year Extra-oral 1 per beneficiary in a 3-year period Medicine Only formulary medicine obtained from a network pharmacy prescribed by a Denis network dentist 100% of the MMAP according to the dental formulary core benefits Trauma recovery s are subject to authorisation, PMB protocols and case management. Remember to authorise the emergency hospital admission on the first workday after the admission. Description TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF: Motor vehicle accidents Stab wounds Gunshot wounds Head trauma Burns Near drowning Subject to authorisation, PMB protocols and case management 100% of the cost Unlimited POST-EXPOSURE PROPHYLAXIS 11 MMAP Maximum Medical Aid Price PMB Prescribed minimum benefits MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

15 Prescribed minimum benefits (PMB) PMB apply to 270 conditions of which the diagnosis, care and treatment are covered. Medicine for the treatment of the additional 26 specific chronic conditions on the Chronic Diseases List (CDL) will qualify for benefits, subject to treatment guidelines. If you are diagnosed with a PMB condition by your network GP, you must submit the doctor's report on the PMB condition to Medihelp to be considered for pre-authorisation. the report to pmb@medihelp.co.za or fax it to PMB are subject to pre-authorisation, clinical protocols (treatment guidelines) and formularies, and services must be rendered by contracted service providers. If you deviate from the formularies or protocols or are not treated by a contracted service provider, copayments will apply, or services will not be covered. Description DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CHRONIC DISEASES LIST (CDL) Subject to protocols, pre-authorisation and DSPs 100% of the cost Unlimited Co-payments may apply in case of voluntary non-dsp use/protocol deviation Oncology Medihelp s Necesse option offers benefits for the treatment of PMB cancer diagnoses only. 98% of all oncology cases qualify for PMB which Medihelp will cover at 100% of the cost. Medihelp has partnered with ICON (Independent Clinical Oncology Network) as the DSP to assist cancer patients. All cancer patients must be referred to an ICON oncologist, who will then determine the most appropriate treatment option after which an application form will be submitted to Medihelp. s apply only to cancer that meets the definition for PMB as described in the Regulations under the Act: If the cancer involves only the organ of origin If there is no evidence of metastatic spread If there is no irreparable damage to the organ of origin Should the above not apply, if there is a demonstrated five-year survival rate of 10% or more. Important to note: Oncology and oncology-related services (chemotherapy/adjuvant medicine/radiotherapy/brachytherapy/bone marrow or stem cell transplants) must be rendered within the ICON network and according to the ICON protocol. DSP Designated service provider PMB Prescribed minimum benefits ICON Independent Clinical Oncology Network Necesse network GP a general practitioner in the Necesse network 12

16 Oncology contact details: Medihelp Tel: Fax: A list of ICON oncologists is available on our website at Description ONCOLOGY* Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme Radiotherapy Brachytherapy Chemotherapy and associated adjuvant medicine (medicine subject to the MORP) Bone marrow/stem cell transplants (subject to protocols) 100% of the cost Protocol and DSP (ICON) apply Co-payments apply to voluntary nonnetwork services (10%) and/or deviation from the protocol (25%) HIV/Aids (PMB only) OneHealth is the managed healthcare partner for HIV/Aids-related services and postexposure prophylaxis Tel: Emergencies: Fax: Dis-Chem Direct is the designated service provider (DSP) for HIV/Aids medicine Tel: Fax: s are subject to clinical protocols and treatment plans. s are subject to registration on the HIV/Aids programme provided by OneHealth. Description HIV/AIDS (PMB) Antiretroviral therapy and treatment by a DSP (Dis-Chem Direct) 100% of the cost Other services covered as PMB The services below can only be covered if they qualify for PMB. s are subject to pre-authorisation and admission to a Necesse network hospital. A 20% co-payment applies to unauthorised admissions or a 35% co-payment to voluntary admission to a non-network hospital. No benefits are paid for clinical psychology and psychiatric nursing services. You will be liable for the difference in cost if the PMB prosthesis is not obtained from the DSP. * See explanation of terms for more information 13 PMB Prescribed minimum benefits ICON Independent Clinical Oncology Network DSP Designated service provider MORP Medihelp Oncology Reference Price

17 Description RENAL DIALYSIS (PMB) Subject to pre-authorisation and clinical protocols In and out of hospital Acute dialysis Chronic/peritoneal dialysis PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION (PMB) Subject to pre-authorisation, and services must be rendered in an approved network hospital/facility and must be requested by a Necesse network GP or a specialist on referral by a network GP Professional services rendered by a psychiatrist in and out of hospital General ward accommodation Medicine supplied during the treatment in the hospital/facility Outpatient consultations MAXILLOFACIAL SURGERY (PMB) Subject to pre-authorisation and clinical protocols PROSTHESES (PMB) Subject to pre-authorisation, clinical and PMB protocols* Internally implanted prostheses EVARS prostheses Vascular/cardiac prostheses Health-essential functional prostheses Intra-ocular lenses Prosthesis with reconstructive or restorative surgery External breast prostheses (in and out of hospital) MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES Services in and out of hospital and prescribed by a medical doctor Stoma components Incontinence products/supplies CPAP apparatus Prescribed by a medical doctor Subject to pre-authorisation and protocols (out of hospital) 100% of the cost 100% of the cost 100% of the cost 100% of the cost DSP applies 100% of the cost R8 550 per family per year 100% of the cost R8 400 per beneficiary in a 24-month cycle * The member is liable for the cost difference if PMB prostheses are not obtained from the DSP Necesse network GP a general practitioner in the Necesse network PMB Prescribed minimum benefits CPAP Continuous positive airway pressure EVARS Endovascular aortic replacement surgery DSP Designated service provider 14

18 Description ORGAN TRANSPLANT (PMB) Subject to pre-authorisation and clinical protocols 100% of the cost Unlimited Cornea implants (PMB) 100% of the cost R per implant per year Emergencies and out-of-network consultations Emergency transport Emergency transport services are provided and must be pre-authorised by Netcare 911 by phoning , or a 50% co-payment may apply. Netcare 911 also offers support through a 24-hour helpline and a trauma counselling service. Only emergencies that meet the definition on page 31 qualify for PMB. Facility fees and radiology are not covered. Pathology tests must be requested by a medical doctor according to a list of pathology codes and obtained from Lancet/PathCare, or you will be liable for the difference. Your claims If you paid the doctor s account in the case of an emergency or out-of-network consultation, you can submit a claim to Medihelp for a refund, should the claim qualify for benefits. Submit the following for Medihelp by post, fax ( ) or (claims@medihelp.co.za) or use the app: The specified account A copy of your proof of payment The authorisation/referral number for the consultation (in the case of a specialist or other medical practitioner on referral). Description EMERGENCY TRANSPORT SERVICES Provided and pre-authorised by Netcare 911 Transport by road or air within the borders of South Africa only Subject to protocols and pre-authorisation 24-HOUR HELPLINE AND TRAUMA COUNSELLING (Netcare 911) EMERGENCY UNITS AND NON- NETWORK CONSULTATIONS PMB-related emergencies (see definition in explanation of terms ) Unlimited 50% co-payment if not pre-authorised Phone PMB Prescribed minimum benefits MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

19 Description Outpatient emergency unit services and non-network consultations Medicine and services rendered by a non-network medical doctor Pathology requested by a medical doctor Pathology codes and DSP (Lancet/ PathCare) apply 80% of the MT M = R950 per year M+ = R1 950 per year Facility fee and radiology For member s account Hospitalisation You may be admitted to any hospital that is part of the Necesse hospital network. The list of hospitals is available on Medihelp s website at by dialling *120*6364# on a cell phone, or by using Medihelp s member app. For your convenience, we have also included the list of network hospitals on page of this guide. Your Necesse network doctor or the specialist to whom you've been referred will decide whether you should be admitted to hospital. If your specialist consultation has not been pre-authorised, your hospital admission cannot be authorised. All hospital admissions must be pre-authorised well in advance. Obtain immediate authorisation for 19 hospital procedures by using the automated authorisation process on the member secured website (read more on page 23) or phone Medihelp at , hospitalauth@medihelp.co.za or send a fax to In case of an emergency admission after hours the admission must be registered on the first workday after the admission. A 20% co-payment will apply if the hospital admission is not pre-authorised, or a 35% co-payment if you are voluntarily admitted to a hospital that is not part of the Necesse hospital network, except for emergency admissions. Hospital benefits are subject to pre-authorisation, clinical treatment guidelines (protocols) and case management. Should pathology services during hospitalisation not be rendered by Lancet/PathCare, co-payments will apply. Description HOSPITALISATION IN A NETWORK HOSPITAL Subject to pre-authorisation, case management and clinical protocols Intensive care and high care wards Ward accommodation Theatre fees Ward medicine Consultations, surgery and anaesthesia Unlimited 20% co-payment per admission if not pre-authorised, or a 35% co-payment for non-emergency admission or voluntary admission to a non-network hospital M Member DSP Designated service provider MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 16

20 Description APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM HOSPITAL (TTO) (Excluding PMB chronic medicine) PHYSIOTHERAPY AND OCCUPATIONAL THERAPY In hospital STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES In hospital Interventional procedures performed by a radiologist, including material Pathology codes and DSP (Lancet/ PathCare) apply OXYGEN In hospital CLINICAL TECHNOLOGIST SERVICES In hospital CONFINEMENT (childbirth) Subject to pre-authorisation and clinical protocols Non-PMB cases Hospitalisation Midwifery and confinement/delivery Gynaecologist and anaesthetist services Post-natal services PMB cases* Hospitalisation Midwifery and confinement/delivery Gynaecologist and anaesthetist services Post-natal services HOME DELIVERY Subject to pre-authorisation and clinical protocols Professional nursing fees Equipment Material and medicine R320 per admission R8 500 per family per year R per family per year R per family per year R per confinement for an elective caesarean section 20% co-payment per admission if not pre-authorised or 35% co-payment in case of voluntary admission to a nonnetwork hospital Unlimited 20% co-payment per admission if not pre-authorised or 35% co-payment in case of voluntary admission to a nonnetwork hospital R per event 20% co-payment per event if not pre-authorised 17 * Services rendered by a specialist on the Necesse specialist network on referral by a Necesse network general practitioner. TTO To take out (medicine) PMB Prescribed minimum benefits DSP Designated service provider MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

21 Description APPENDECTOMY Subject to pre-authorisation Conventional procedure Unlimited Laparoscopic procedure Hospitalisation: R per beneficiary PROSTATECTOMY Subject to pre-authorisation Conventional or laparoscopic procedure Unlimited Robotic assisted laparoscopic procedure Hospitalisation: R per beneficiary Specialised radiology (MRI, CT imaging and angiography) Specialised radiology must be requested by a specialist on referral by a Necesse network GP, and the specialist consultation must be pre-authorised. You must obtain pre-authorisation for MRI and CT imaging by phoning Description SPECIALISED RADIOLOGY In and out of hospital Only services requested by a specialist on referral by a Necesse network GP and subject to clinical protocols MRI and CT imaging (Subject to pre-authorisation) Angiography R per family per year Dental surgery under general anaesthesia in a network hospital/ day clinic only Dental surgery may only be done in a network hospital or network day clinic. s are subject to pre-authorisation, Denis managed care protocols and services must be rendered by a Denis network dentist. Dental services that are excluded from benefits are listed on page 37. Description DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA In a network hospital/day clinic and prescribed by a Denis network dental practitioner Subject to pre-authorisation and Denis managed care protocols Only PMB services and extensive dental treatment for children younger than 5 years once per lifetime 20% co-payment if not pre-authorised or a 35% co-payment in case of voluntary admission to a non-network hospital GP General practitioner CT Computerised tomography MRI Magnetic resonance imaging PMB Prescribed minimum benefits MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 18

22 Sub-acute care and private nursing services as an alternative to hospitalisation s for these services are subject to pre-authorisation and case management. Phone or fax or hmanagement@medihelp.co.za. Private nursing benefits exclude day-to-day services such as bathing and general care. Description SUB-ACUTE CARE AND PRIVATE NURSING SERVICES AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation, and services prescribed by a medical doctor (Excluding day-to-day care) R per family per year 20% co-payment if not pre-authorised supporting information Cardio risk management programme In order to manage risks and costs associated with cardio conditions, a cardio risk programme is available for Necesse members for individuals older than 60 years who concurrently suffer from diabetes, hypertension and high cholesterol. After registration on the programme, a basket of services will be delivered by appointed network doctors to Necesse patients suffering from these conditions to assist them with the management of the diseases. 19

23 Finding network providers on your cell phone *120*6364# It has never been easier to find a network doctor, pharmacy, dentist or hospital near you Medihelp s Necesse Network Locator helps you locate your nearest Necesse network provider. This is achieved by smart technology that determines your cell phone s location and then identifies doctors or other network providers in the area that you may possibly visit. The service will cost you the standard network rate and is available on any type of cell phone, regardless of model or age. It is especially helpful in the following instances: If you are away from home, e.g. on holiday, and quickly need to locate a network provider; If you have moved to a new suburb, town or city and need to choose a new network doctor; or If you are at work and you need to visit a doctor, but your regular network doctor is too far away. Follow these easy steps: *120*6364# Step 1: Dial *120*6364# and follow the instructions on the screen (select 2 for Necesse). Welcome to Medihelp Necesse network locator. What do you need to find? 1) General practitioner 2) Pharmacy 3) Hospital 4) Dentist Step 2: Choose from the list of types of providers by typing the applicable number and selecting or enter on the phone. Dr A 1086 Schoeman Street Hatfield, Pretoria Tel: ) SMS details 2) Back 3) Home 4) Quit Final step: Get the details, choose to receive an SMS or quit. You can even go back a step if you want another doctor. Your closest general practitioners are: 1) Dr. A 2) Dr. B 3) Dr. C 4) Dr. D 5) Dr. E 6) Next Step 3: Choose your doctor by typing the number before his/her name on your screen and selecting or enter on the phone. 20

24 Specialist network Medihelp s Necesse specialist network provides treatment for prescribed minimum benefit (PMB) conditions. By visiting specialists who form part of this network, you can limit your out-of-pocket expenses. Necesse network option specialists covering 21 disciplines Where can I obtain a list of network specialists? Visit Medihelp s website at and go to Provider search. Alternatively, use Medihelp s app to locate the nearest network specialist. Is the specialist you visit part of the applicable specialist network? Your PMB services will be paid at cost, and other services at the Medihelp tariff. You will be responsible for the difference between the cost and the Medihelp tariff. Tip: Talk to your specialists about their fees To prevent any surprises on your specialists accounts, simply phone them before you receive the consultation or treatment and enquire about their fees. This way, you will know in advance how much your co-payment (if any) will be. You can also negotiate a reduced fee with the specialists or arrange payment terms. Network specialists operate at network hospitals Network specialists operate at network hospitals, so it is important to ensure that the specialist you choose operates at your network hospital. 21

25 necesse hospital network Necesse private hospital and day clinic network You have access to 124 private hospitals and day clinics countrywide. Please ensure that there is a network hospital near you, and that it will provide in your specific healthcare needs. Avoid a 35% co-payment for a voluntary admission to a non-network hospital, or a 20% co-payment for unauthorised hospital admissions. Specialist network Remember certain specialists only admit patients to the hospital where they have their consultation rooms, so you ll have to make sure that your specialist operates at a network hospital. A specialist network for the Necesse option is available for PMB services to contain co-payments. Where to find a network hospital or day clinic The Medihelp website lists all the network hospitals, day clinics and specialists. Visit Dial *120*6364# on your cell phone, or download the Medihelp member app, which is available on these devices: ios Android Windows 22

26 How to pre-authorise your hospital admission There are various ways to pre-authorise your planned hospital admission well in advance, and we ve developed an automated authorisation system that provides immediate authorisation 24 hours a day, seven days a week for 19 procedures. Immediate e-auth Procedures that can be automatically authorised Adenoidectomy Dilatation and curettage Myomectomy Appendectomy Gastroscopy Myringotomy Caesarean section Hysterectomy Normal birth Cholecystectomy Hysteroscopy Sterilisation Circumcision Intra-uterine devices Tonsillectomy Colonoscopy Laparoscopy Vasectomy Cysto-urethroscopy Information you need to pre-authorise You need to obtain the following from your doctor: The name of the procedure The ICD-10 (diagnostic) code E-auth process Step 1 Visit Medihelp s website at Step 2 Look for the Login/Register block, select Members to go to the member secured site and click on Login/Register. If you need to register, select Register, follow the easy steps to register and then log on to the member secured site. Step 3 Click the Pre-authorisation button on the menu and select Hospital authorisation. Then follow the steps to authorise your hospital admission and within moments you will receive details of the pre-authorisation via SMS and an with your reference number. Approval of other procedures Apply via Medihelp s secured site for members or use one of the authorisation channels listed below. Other ways to apply for pre-authorisation Authorise via our member app for smartphones Use the Medihelp Member app and select e-services Available on istore and Google Play 23 ios Android Windows

27 Other authorisation channels Phone Fax Dental Information you will need to pre-authorise Your membership number The details of the patient The procedure and diagnosis codes (get these from your doctor) The treating doctor s details The details of the hospital to which the patient will be admitted The date of admission For certain procedures, additional information may be required, such as medical reports, X-rays or blood test results. Medihelp s pre-authorisation consultant will advise you on what is needed. Details of the anaesthetist (for dental procedures). Necesse private hospitals and day clinics Eastern Cape City/town Name Practice No East London Life Beacon Bay Hospital Grahamstown Settlers Hospital Humansdorp Isivivana Private Hospital (maternity & neonatal only) Port Alfred Port Alfred Hospital Port Elizabeth Greenacres Hospital Port Elizabeth Medical Forum Theatre Queenstown Life Queenstown Private Hospital Uitenhage Cuyler Clinic Free State City/town Name Practice No Bethlehem Mediclinic Hoogland Bloemfontein Mediclinic Bloemfontein Kroonstad Koinonia Theatre ( Dr LJ van Wyk) (dental procedures only) Kroonstad Kroon Hospital Welkom Mediclinic Welkom

28 Gauteng City/town Name Practice No Alberton Clinton Clinic Alberton Union Hospital Benoni Lakeview Hospital (dental procedures only) Benoni Linmed Hospital Boksburg Boksburg Medical & Dental Centre (dental procedures only) Boksburg Sunward Park Hospital Bronkhorstspruit Bronkhorstspruit Hospital Heidelberg Suikerbosrand Clinic (maternity & neonatal only) Johannesburg Garden City Clinic (maternity & neonatal only) Johannesburg Mediclinic Morningside Johannesburg Mediclinic Sandton Johannesburg Mulbarton Hospital Johannesburg Parklane Clinic (maternity & neonatal only) Johannesburg Rand Clinic Johannesburg Wits University Donald Gordon Medical Centre Kempton Park Birchmed Surgical Centre (dental procedures only) Krugersdorp Krugersdorp Private Hospital Krugersdorp Protea Clinic Krugersdorp Pinehaven Hospital Midrand Netcare Waterfall City Hospital Midstream Mediclinic Midstream Pretoria Akasia Hospital Pretoria Bougainville Private Hospital Pretoria Life Groenkloof Hospital (oncology only) Pretoria Mediclinic Gynaecological Hospital Pretoria Mediclinic Heart Hospital Pretoria Mediclinic Kloof Pretoria Mediclinic Legae Pretoria Mediclinic Medforum Pretoria Mediclinic Muelmed

29 Gauteng City/town Name Practice No Pretoria Montana Private Hospital Pretoria Medkin Clinic (dental procedures only) Pretoria Pretoria North Day Clinic (dental procedures only) Soweto / Lenasia Lenmed Clinic Soweto / Lenasia Lenmed Daxina Private Hospital Springs East Rand N17 Private Hospital Vanderbijlpark Mediclinic Emfuleni Vanderbijlpark PJ Schutte Theatre Unit (dental procedures only) Vereeniging Mediclinic Vereeniging KwaZulu-Natal City/town Name Practice No Amanzimtoti Kingsway Hospital Ballito Alberlito Hospital Durban Chatsmed Garden Hospital Durban Bluff Medical & Dental Centre Durban St Augustine s Hospital Durban Pinetown Medicross Theatre Durban Parklands Hospital Empangeni Empangeni Garden Clinic Howick Mediclinic Howick Kokstad Kokstad Private Hospital Margate Margate Private Hospital Newcastle Mediclinic Newcastle Nongoma Nongoma Private Hospital Pietermaritzburg Mediclinic Pietermaritzburg Pinetown Malvern Medical & Dental Centre Pongola Pongola Hospital Port Shepstone Hibiscus Hospital Richards Bay The Bay Hospital Shelly Beach Shelly Beach Day Clinic Tongaat Victoria Hospital Umhlanga Umhlanga Hospital

30 Limpopo City/town Name Practice No Bela Bela St Vincent s Hospital Lephalale Marapong Private Hospital Makhado Zoutpansberg Private Hospital Polokwane Mediclinic Limpopo Polokwane Mediclinic Limpopo Day Clinic Thabazimbi Mediclinic Thabazimbi Tzaneen Mediclinic Tzaneen Mpumalanga City/town Name Practice No Barberton Mediclinic Barberton emalahleni emalahleni Private Hospital emalahleni emalahleni Day Hospital Ermelo Mediclinic Ermelo Middelburg Middelburg Private Hospital Nelspruit Mediclinic Nelspruit Secunda Mediclinic Secunda Trichardt Mediclinic Highveld North West City/town Name Practice No Brits Mediclinic Brits Klerksdorp Wilmed Park Private Hospital Klerksdorp Sunningdale Hospital Marikana Andrew Saffy Memorial Hospital Potchefstroom Mediclinic Potchefstroom Rustenburg Peglerae Hospital Rustenburg Ferncrest Hospital Vryburg Vryburg Private Hospital

31 Northern Cape City/town Name Practice No Kathu Lenmed Health Kathu Private Hospital Kimberley Mediclinic Kimberley Upington Mediclinic Upington Western Cape City/town Name Practice No Atlantis Wesfleur Private Clinic Cape Town Melmomed Gatesville Cape Town Christiaan Barnard Memorial Hospital (paediatric oncology only) Cape Town Mediclinic Cape Gate Cape Town Mediclinic Cape Town Cape Town Mediclinic Constantiaberg Cape Town Mediclinic Durbanville Cape Town Mediclinic Durbanville Day Hospital Cape Town Mediclinic Louis Leipoldt Cape Town Mediclinic Milnerton Cape Town Mediclinic Panorama Ceres Ceres Private Hospital George Mediclinic Geneva George Mediclinic George Hermanus Mediclinic Hermanus Knysna Knysna Private Hospital Mosselbay Bayview Hospital Oudsthoorn Mediclinic Klein Karoo Paarl Mediclinic Paarl Plettenberg Bay Mediclinic Plettenberg Bay Somerset West Mediclinic Vergelegen Stellenbosch Mediclinic Stellenbosch Strand Mediclinic Strand Vredenburg West Coast Private Hospital Worcester Mediclinic Worcester Medihelp may change the information contained in this document from time to time and will publish any changes on our website at 28

32 Important contact numbers and pre-authorisation Certain benefits are subject to pre-authorisation of the services. This table explains which services require pre-authorisation, who you must phone and what information you should have ready when phoning. Remember that you, any family member or even your doctor may phone to obtain preauthorisation. Pre-authorisation does, however, remain the responsibility of the member. Also remember that you can apply for pre-authorisation with the app or on the secured website for members. We also have an immediate pre-authorisation process for 19 procedures available on the secured website for members (see page 23 for more details). 29 Services Contact details Have the following information ready Hospitalisation and specialist referrals Including psychiatric conditions but excluding hospitalisation for dentistry Admissions only to Necesse network hospitals All hospital admissions must be pre-authorised Emergency transport services Dental surgery under general anaesthetic, and under conscious sedation in the Denis network dentist s rooms Specialised radiology (MRI and CT imaging in and out of hospital) Pregnancy benefits Chronic medicine (PMB/ CDL conditions) Specialist consultations Medihelp Fax: hospitalauth@medihelp.co.za Get e-authorisation on the secured website for members at Netcare Denis Fax: medihelpenq@denis.co.za Medihelp Fax: Medihelp Fax: necesse@medihelp.co.za Medihelp Fax: (PMB chronic medicine) Fax: (more than 30 days supply) medicineapp@medihelp.co.za Medihelp Fax: hospitalauth@medihelp.co.za Member number Details of the patient, network doctor/specialist and network hospital Diagnostic and procedure codes Date of admission Member number Patient details Member number Details of the patient, dentist, anaesthetist and network hospital Item and procedure codes Member number Details of the patient, radiologist and requesting medical doctor Diagnostic and procedure codes Service date Member number Details of the patient Member number Details of the patient Completed PMB chronic medicine application form Member number Details of the patient, network doctor and specialist Diagnostic and procedure codes (if applicable) Service date Completed specialist referral form