user guide maxima entryzone major medical benefit All costs for hospitalisation are covered from this benefit

Transcription

1 user guide 2013 BENEFIT major medical benefit All costs for hospitalisation are covered from this benefit Overall annual limit (OAL) Healthcare Professional Tariff in hospital (HPT) Specialists tariff - Fedhealth Specialist Partners - Non-Fedhealth Specialist Partners ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Unlimited at network hospitals only. R4 500 co-payment on voluntary use of non-network hospital Covered at cost Covered at 100% of Fedhealth Rate Other Healthcare Professionals including GPs Prescribed Minimum Benefits (PMB) Hospitalisation costs Co-payments Alternatives to hospitalisation Sub-acute facilities, physical rehabilitation facilities, nursing services, private nurse practitioners & nursing agencies Ambulance services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Additional medical services (occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Dentistry: Maxillo-facial surgery Emergency treatment in a casualty ward Female health benefit: contraceptives Hospice care Immune deficiency related to HIV infection Oncology - Specialised medication Organ transplant including immunosuppression medication - Corneal graft Pathology Post-hospitalisation benefit Post-natal midwifery benefit Covered at 100% of Fedhealth Rate Unlimited in state hospitals Unlimited at negotiated tariff at network hospitals only. R4 500 co-payment on voluntary use of non-network hospital See co-payment table Unlimited at negotiated tariff PMB level of care only Unlimited with Europ Assistance Unlimited at cost Unlimited (See HPT) No benefit Unlimited at Fedhealth Rate No benefit R at Fedhealth Rate Unlimited (See HPT) PMBs only at ICON* No benefit PMBs only in state facilities No benefit Unlimited at Fedhealth Rate Up to 30 days after discharge at Fedhealth Rate 4 days at Fedhealth Rate Prostheses maxima entryzone - Internal - External *ICON - Independent Clinical Oncology Network PMBs only PMBs only HPT - Healthcare Professional Tariff

2 BENEFIT major medical benefit (continued) Psychiatric services Renal Dialysis (chronic) Haemodialysis and peritoneal dialysis Specialised medication (eg. biologicals) benefit (oncology & non-oncology) Specialised radiology Take-out medicines *MPL - Medicine Price List ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED PMBs only PMBs only in state facilities No benefit co-payments Unlimited at Fedhealth Rate 7 days medication per hospital event at MPL* CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY All hernia procedures, Back & neck pain, Back surgery, Bunion procedures, Cataract surgery, Elective caesarean sections, Gastritis/ dyspepsia/ heartburn, Hysterectomy (unless for cancer), Nasal procedures, Scopes (upper GI endoscopy, colonoscopy, cystoscopy), Skin biopsy/ excision, Tonsil/ adenoid procedures, Varicose vein procedures Arthroscopic procedures R3 350 Ankle, Knee, Shoulder R3 350 Laparoscopic procedures Diagnostic, Nissen/ Toupey R3 350 ADDITIONAL ARTHROSCOPIC AND LAPAROSCOPIC PROCEDURES WHERE THE SCHEME WILL NOT FUND LAPAROSCOPIC EQUIPMENT AND DISPOSABLES Appendectomy, Hernia repairs (other than inguinal repair), Hip, Hysterectomy, Nephrectomy, Pyeloplasty, Radical Prostatectomy, Splenectomy, Unilateral Inguinal Hernias, Wrist Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered major medical benefit All authorised costs for hospitalisation are covered from this benefit at the Healthcare Professional Tariff. Please remember to familiarise yourself with the network provisions for this option. This includes network specialits and hospitals. Hospital costs will be covered unlimited, from this benefit. However, certain benefits are subject to and limited by case management and managed care protocols. These protocols have been introduced to ensure best quality treatment at best rates. Consult the Major Medical Benefit table for detail on these interventions and their limits. The Major Medical Benefit on Maxima EntryZone is subject to members making use of the Maxima EntryZone hospital network. Voluntary use of a non-network hospital will result in a R4 500 co-payment on the hospital account. However, treatment of an emergency medical condition may take place at any hospital. (See details of an emergency medical condition below). Details of the Maxima EntryZone hospital network are featured further in this user guide. Involuntary use of a non-network hospital as a result of an emergency medical condition An emergency medical condition is the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person s life in serious jeopardy. Once the condition has been stabilised and the person can be safely transferred to another facility, then co-payments for use of a non-network facility will become applicable if the member is unwilling to be transferred to a network facility. Fedhealth Specialist Partners: the Scheme has partnered with specialists across all disciplines in order to ensure that members have no co-payments when visiting these specialists. Making use of a Fedhealth Specialist Partner in hospital will ensure no co-payments, as fixed rates have been negotiated with these partners. Voluntary use of a non-fedhealth Specialist Partner will result in lower reimbursement rates of your inhospital specialist account. Please note that certain procedures performed by a specialist may still attract a co-payment whether a network specialist is used or not. Selected procedures performed in a day ward, day clinic and the doctor s rooms are also covered from this benefit. For a list of these procedures and pre-authorisation, please phone the Fedhealth Customer Contact Centre on or visit the Fedhealth website on Specialised Radiology, for example MRI and CT scans, is also covered from the Major Medical Benefit whether the procedure is performed in hospital or not. Treatment received in a casualty ward for trauma as well as any other treatment in a casualty ward that is immediately followed by a hospital admission, is covered from the Major Medical Benefit. Trauma is defined as a physical injury to the body by an external force that requires immediate attention, for example stitches. Certain treatment arising from a hospital event, for example physiotherapy, x-rays and blood tests are covered for 30 days from date of discharge from hospital from the Major Medical Benefit. For a list of these treatments and pre-authorisation, please phone the Fedhealth Customer Contact Centre on or visit the Fedhealth website on www. fedhealth.co.za Oncology benefit: The Scheme has contracted with Independent Clinical Oncology Network (ICON) for the provision of oncology treatment. ICON is a network of oncologists that includes 75% of all practicing oncologists in South Africa. Details of the ICON network are available on their website at or with a call to your Oncology Case manager on See the table below for details of oncology cover for your option. Oncology Limit Specialised Drug Sublimit Brachytherapy materials Applicable Protocols DSP / Preferred Provider Status PMB s only No benefit No benefit Standard ICON - DSP A Designated Service Provider (DSP) means that you must use the ICON network for oncology treatment. Oncology reimbursement rate - ICON is the DSP for oncology treatment on your option; therefore a 40% co-payment will be levied on members who voluntarily elect to make use of a non-icon doctor. ICON oncologists will be reimbursed in full at the ICON rate. Oncologists outside of the ICON network will only be reimbursed at 100% of the Fedhealth Rate regardless of whether care takes place in or out of hospital. Please remember that your option only covers oncology treatment for PMBs. All costs covered from the Major Medical Benefit need to be pre-authorised by the Authorisation Centre on

3 prescribed minimum benefits (PMBs) All medical schemes are required by law to cover 270 hospital based conditions, 25 chronic conditions in full without co-payment or deductibles, as well as any emergency treatment and certain out of hospital treatment. This means that all schemes must provide PMB level of care at cost for these conditions. The Medical Schemes Act 131 of 1998 allows schemes to require members to make use of Designated Service Providers (DSPs) in order for a member to be entitled to funding in full. Schemes may also apply Formularies a list of medicines which should be used to treat PMBs, and Managed care protocols based on evidence-based medicine and cost-effectiveness principles to manage this benefit. Fedhealth has designated their Specialist Partners, Network Hospitals, Network GPs and a designated pharmacy network, the MEDI-Rite group of pharmacies, as the Designated Service Providers for the provision of PMBs (as well as the State). This means that a member must make use of a Fedhealth Specialist Partner, a Network Hospital, a Network GP or the designated pharmacy network, in order for the cost to be funded in full. Should the member not use these DSPs for the treatment of a PMB condition, the Scheme will reimburse treatment at the non-fedhealth Partner Rate applicable to your option. Co-payments are applicable to the voluntary use of non-dsps. It is important to note that qualification as a PMB is not based solely on the diagnosis (condition) but also on the treatment provided (level of care). This means that although your condition may be a PMB condition, the Scheme would only be obliged to fund it in full if the treatment provided was deemed to be PMB level of care. screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health BENEFIT CRITERIA ALL LIMITS ARE PER BENEFICIARY Women s Health Breast cancer screening with mammography Cervical cancer screening Children s Health Immunisation Programme (as per State EPI) Cardiac Health Cholesterol screening (full lipogram) General General practitioner consultation (in network only) Flu vaccination Women; 50 to 70 Women; 21 to 65 Various All lives; older than 20 All lives All lives 1 every 3 years 1 every 3 years Various 1 every 5 years 1 every year 1 every year immunisation benefit AGE OF CHILD VACCINE At Birth Tuberculosis (Bacilles Calmette Guerin) OPV (0) Oral Polio Vaccine 6 Weeks OPV (1) Oral Polio Vaccine RV (1) Rotavirus Vaccine DTaP-IPV//Hib (1), Diptheria, Tetanus, accelular Petussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenza type b combined Hep B (1) Hepatitis B Vaccine PCV 7 (1) Pneumococcal Conjugated Vaccine 10 Weeks DTaP-IPV//Hib (2), Diptheria, Tetanus, accelular Petussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenza type b combined Hep B (2) Hepatitis B Vaccine 14 Weeks RV (2) Rotavirus Vaccine (should not be administered after 24 weeks) DTaP-IPV//Hib (3), Diptheria, Tetanus, accelular Petussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenza type b combined Hep B (3) Hepatitis B Vaccine PCV7 (2) Pneumococcal Conjugated Vaccine 9 Months Measles Vaccine (1) PCV 7 (3) Pneumococcal Conjugated Vaccine 18 Months DTaP-IPV//Hib (4), Diptheria, Tetanus, accelular Petussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenza type b combined Measles Vaccine (2) 6 Years Td Vaccine Tetanus and reduced strength of diphtheria Vaccine 12 Years Td Vaccine Tetanus and reduced strength of diphtheria Vaccine internal prosthesis PMBs only

4 maxima entryzone network hospitals HOSPITAL PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Mercantile Private Hospital Eastern Cape Korsten St Georges Hospital Eastern Cape Centrahill St James Hospital Eastern Cape Southernwood St Mary's Private Hospital Eastern Cape Umtata Bloemfontein Eye Centre Free State Bloemfontein Pasteur Hospital Free State Bloemfontein Rosepark Hospital Free State Bloemfontein Bougainville Private Hospital Gauteng Hercules Brenthurst Clinic Gauteng Johannesburg Carstenhof Clinic Gauteng Midrand Cormed Clinic Gauteng Vanderbijlpark Dalview Clinic Gauteng Brakpan Flora Clinic Gauteng Roodepoort Fourways Hospital Gauteng Fourways Gardens Glynnwood Hospital Gauteng Benoni Louis Pasteur Hospital Gauteng Pretoria Central Midvaal Private Hospital (Pty) Ltd Gauteng Three Rivers Robinson Hospital Gauteng Randfontein Roseacres Clinic Gauteng Primrose Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth Durdoc Clinic Kwa-Zulu Natal Durban Central Entabeni Private Hospital Kwa-Zulu Natal Durban Maxwell Clinic Kwa-Zulu Natal Qualbert Mount Edgecombe (Phoenix) Hospital Kwa-Zulu Natal Mount Edgecombe Westville Hospital Kwa-Zulu Natal Westville Zoutpansberg Private Hospital Limpopo Polokwane Cosmos Hospital Mpumalanga Witbank Peglerae Private Hospital North West Rustenburg Mediclinic Kimberley Northern Cape Kimberley Bay View Private Hospital Western Cape Mossel Bay Blaauwberg Hospital Western Cape Bloubergrant Mediclinic Cape Gate Western Cape Cape Gate Mediclinic Cape Town Western Cape Mill Street Ceres Private Hospital Western Cape Ceres Claremont Hospital Western Cape Claremont Kingsbury Hospital Western Cape Claremont Mediclinic Geneva Western Cape George Mediclinic George Western Cape George Mitchells Plain Medical Centre Western Cape Cape Town West Coast Private Hospital Western Cape Vredenburg chronic disease benefit Medication for approved chronic diseases is covered from this benefit Limit Conditions covered Formulary Designated Service Provider (DSP) COVER Prescribed Minimum Benefits only See list below Restrictive formulary MEDI-Rite pharmacy HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMIS- SION, RAPE & POST-EXPOSURE PROPHYLAXIS Limit Unlimited Non-compliance with DSP and/ or formulary requirements will attract a co-payment of 40%. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. 25 PRESCRIBED CHRONIC CONDITIONS Addison s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, COPD/ Emphysema/ Chronic Bronchitis, Chronic Renal Disease, Coronary Artery Disease, Crohn s Disease, Diabetes Insipidus, Diabetes Mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis chronic disease benefit The Chronic Disease Benefit covers the 25 Prescribed Minimum Benefit (PMB) conditions on Maxima EntryZone. Consult the Chronic Disease Benefit table for a list of these conditions. Formularies and DSP: The Scheme makes use of formularies and a Designated Service Provider (DSP) to manage the cost and ensure accessibility and appropriate level of care for all our members. - Formularies: A formulary is an approved list of medication for each of the chronic conditions covered by the Scheme. These formularies should in no way compromise the quality of healthcare that you, the member receives. Formularies are also subject to the Medicine Price List (MPL). On your option your chronic medication is subject to Fedhealth s Restrictive formulary for the PMB conditions - DSP: Fedhealth s Designated Service Provider (DSP) is the MEDI- Rite group of pharmacies, located in Checkers and Shoprite supermarkets. On your option you are required to make use of a MEDI-Rite pharmacy for your chronic medication. Co-payments: Your option is subject to the Restrictive formulary. If you choose to use out-of-formulary medication, please note that this will attract a 40% co-payment on the cost of the medication. Your option also requires you to use a MEDI-Rite pharmacy. If you choose to use a service provider of your choice, please note that this will attract a 40% co-payment on the cost of the medication. Medicine Price List (MPL): Your medication will be covered at the Medicine Price List (MPL) rates. MPL is a reference price list that benchmarks each product against generically similar products. It does not restrict member s choice, but limits the amount that the Scheme will refund for each product. The MPL reference price is set at a level to ensure that a number of medicines will be available without any co-payment. Treatment Guidelines: The Scheme has established treatment guidelines for the 25 PMB chronic conditions to ensure that you have access to appropriate treatment for your condition. You will receive details of the treatment guidelines applicable to you once you register for one of these conditions and the Scheme has received your first claim relating to this condition. How to apply for the Chronic Medicine Benefit: On diagnosis of a listed chronic condition you, your doctor or pharmacist will need to apply for chronic medication telephonically or online via the Medscheme website. Telephonically: You can call Chronic Medicine Management (CMM) between 08h30 and 17h00, Monday to Friday, on

5 chronic disease benefit continued Online: You may also apply for chronic medication 24 hours a day by logging onto the Medscheme website ( If you have not completed an online application before, you will be prompted to register as a first time user since a login username and password will be requested. Once you have registered and your profile is open, click on my authorisations and then select my chronic application. Select the beneficiary for whom you would like to apply and then click on the Chronic authorisation button at the bottom of the page. Then select New Chronic Application. For both telephonic and online applications, we will require the following information: Membership number Dependant code ICD10 code Drug Name, strength and quantity Prescribing Doctor s practice number Diagnostic test results, e.g. Total Cholesterol, LDL, HDL, glucose tests, thyroid (depending on your condition). Once you have completed the registration process, you will receive an immediate response. Where more clinical information is required, members of the clinical team will review the information supplied and correspond with you and your doctor. Once your application has been approved: CMM will provide you with your medicine access card, which will list the approved medicines to be covered from this benefit. Once you have received your medicine access card, your doctor will need to provide you with a repeat prescription for the approved medicines for a maximum of six months (your doctor is legally not allowed to give you a repeat for more than six months). What to do if your authorised chronic medication changes: If your doctor decides to change your medication, or dosage, CMM needs to be advised. The quickest and simplest way would be for your doctor to inform CMM telephonically on Within 24 hours, a temporary medicine access card will be sent to your pharmacy enabling them to dispense your medicine without delay. Alternatively, you can also apply for the change in medication online at Your new medicine access card will be mailed to you. Make sure your doctor provides you with an updated repeat prescription to match the approved medicines on your medicine access card. Fedhealth offers Disease Management Programmes that support specific diseases. These programmes are offered at no additional cost. Aid for AIDS (AfA) AfA is a comprehensive HIV disease management programme with access to anti-retrovirals and related medicines as well as post-exposure preventative medication. Ongoing patient and provider support as well as regular monitoring of disease progression and response to therapy is provided. To join AfA call them in confidence on Your doctor may also call AfA on your behalf. AsthmaCare Most people with asthma should be able to enjoy a normal lifestyle, including getting a good night s sleep and being able to participate in sport and other normal daily activities. AsthmaCare enables you to achieve this by focusing on the appropriate use of medicine. The programme also provides education and counselling on issues that will help you to clearly understand and manage the disease. Phone or diseasemanagement@medscheme.co.za for more detail or to register. CardioCare Anyone who has had angina or a heart attack is well aware of how important good medicine management is and how critical it is to tackle any lifestyle risks you may have. CardioCare focuses on members who have coronary heart disease, with the aim of preventing heart attacks. The programme promotes healthy lifestyle and the appropriate monitoring and treatment of risk factors. Phone or diseasemanagement@medscheme.co.za for more detail or to register. DiabeticCare This programme helps you to control your blood sugar. It also addresses the importance of screening tests and the necessity of lifestyle adjustments, which can vastly improve the well-being of diabetic patients. The programme also educates you on correct medicine management and monitoring. Phone or diseasemanagement@medscheme.co.za for more detail or to register. Oncology Disease Management Programme (ODM) On diagnosis of cancer, it is important that you register on the Oncology Disease Management Programme (ODM). You can call them on and register. The programme aims to assist your doctor to ensure best treatment and support. Your oncology benefit covers the following expenses: chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology. Specialised radiology, for example MRI and CT scans, will be covered from the unlimited Major Medical Benefit. No specialised medication benefit is available on Maxima EntryZone. Remember that Fedhealth allows option upgrades any time of the year within 30 days of diagnosis of a dread disease like cancer. Changes in your oncology medication need to be communicated to ODM as soon as possible by faxing the amended treatment plan to or ing cancerinfo@medscheme.co.za.

6 day-to-day benefit PMB level of care at Specialist Network Partners, GP Network Partners and designated Pharmacy provider only contributions maxima entryzone Member 883 Adult Dependant 660 Child Dependant 297 unique benefits At Fedhealth we pay more from Risk than most other schemes. Specialised Radiology Fedhealth is one of the few medical schemes that covers specialised radiology, for example MRI and CT scans from the Major Medical Benefit, irrespective of whether the procedure is performed in or out of hospital, provided pre-authorisation has been obtained from the Authorisation Centre. If you are in hospital, you will require an additional authorisation for a specialised radiological procedure. Emergency treatment Did you know Fedhealth is one of the only schemes that pays for trauma treatment from the Major Medical Benefit? According to the rules of the Scheme, a trauma or emergency treatment is defined as a physical injury caused to the body by an external force, which requires immediate attention or, for life threatening conditions, that require immediate hospitalisation after treatment in the trauma unit. Claims will be paid from Risk if... A member visits the trauma unit of a clinic or hospital for emergency treatment such as stitches A member visits the clinic or hospital with a life threatening condition and is admitted immediately for further treatment.

7 unique benefits continued Claims will NOT be paid from Risk if... A member visits their GP for an emergency treatment such as stitches and the procedure takes place in the doctor s consulting rooms A member visits the trauma unit of a clinic or hospital with an ailment other than a life threatening condition and is not admitted immediately into hospital. If these claims are not authorised they will be paid from the member s own pocket. This authorisation must be obtained within 24 hours of treatment. Child dependant status up to 27 years Fedhealth will charge the child dependant rate for children still studying or financially dependent on the principal member up to the age of Day post-hospitalisation benefit The Scheme provides for certain treatments up to 30 days after discharge from hospital to be paid from Risk. This benefit is designed to: Minimise the member s stay in hospital Ensure the completion of treatment for a particular condition. This benefit covers: Treatment at 100% of the Fedhealth Rate Post-hospital treatment up to 30 days from date of discharge from hospital. It includes complications that might arise from hospitalisation Physiotherapy; occupational therapy; speech therapy; x-rays, ultrasounds and radio-imaging or radio-isotope scans and pathology tests. The following conditions apply to the 30 day post-hospitalisation benefit: Members must pre-authorise treatment prior to the treatment date Only treatment as a result of a hospital event will be covered, i.e. related to the original diagnosis If the member does not pre-authorise treatment, the member will pay for these expenses from their own pocket. Take-out Medicines If you or one of your dependants has been admitted to hospital, your doctor may want to give you medication at the time of your discharge. This is referred to as Take-out Medicine. Fedhealth covers this medication from the Major Medical Benefit, which is a Risk benefit. The Take-out medicine benefit covers a maximum of seven days of medication. The medication must both be dispensed by the hospital and reflect on the original hospital account. If you are given a prescription for Take-out medicine and take this prescription to a pharmacy, the claim will be paid from your own pocket. Professional sports and hazardous pursuits Fedhealth is one of the few schemes that offers full cover to people who partake in professional, adventurous and even extreme sports, for example scuba diving, skydiving, bungee jumping, hunting and mountaineering. Expenses will be covered according to Scheme rules. Trauma Counselling After a traumatic experience, for example falling victim to crime or a motor vehicle accident, Fedhealth provides emotional and practical support through ICAS. Call them on Disease management programmes Fedhealth believes in holistic treatment for members suffering from serious diseases such as diabetes, AIDS and cancer by providing various management programmes. 24 Hour Nurseline The 24 hour Fedhealth Nurseline is available for assessing day-to-day symptoms, emergency medical advice, health knowledge (e.g. explanation of medical terms, procedures and test results), drug database (e.g. complete information on medication, contra-indications, etc), stress management, poisoning and teenage support. Call them on Fedhealth Baby The Fedhealth Baby programme has been put together by experts with you and baby in mind. From great give-aways, discounts, education and just plain fun, you ll find that the Fedhealth Baby programme is there to make your experience all the more special. We offer the following benefits: A Fedhealth Baby Bag packed to the brim with quality products; from all the baby care products you ll ever need, to nappies, a Having your baby handbook and more! All especially chosen to take care of your little one from top to toe Discounts for the best baby brands including Huggies, Chelinos, Living & Loving, Preggie Bellies, Lansinoh and a whole lot more On-going communication and education in the form weekly s to mum and bi-monthly s to dad! Health profiling for each trimester 24 hour Medical Advice Line Funding for Doula (labour support) assistance during natural birth New birth card Immunisation s to keep our Fedhealth parents up to date. In addition, a Fedhealth Baby representative will maintain contact over each trimester to make sure mother and baby are making healthy progress. Any Fedhealth member or dependant who is pregnant can register on the Fedhealth Baby programme at no additional cost by calling them on Emergency Medical Services As a Fedhealth member, you can contact Europ Assistance for a range of emergency services on These services include: Emergency road or air response Medical advice in any emergency situation Delivery of medication and blood Patient monitoring Care for stranded minors or frail companions 24-hour personal health adviser. Procedures performed in a day ward More than 60 procedures that can safely be performed in day wards, day clinics and the doctor s rooms are also covered from the Major Medical Benefit and not from your own pocket, for example vasectomies and gastroscopies.

8 important user tips Pre-authorisation You need authorisation for any benefit payable from the Major Medical Benefit, for example, a planned or emergency hospital admission, specialised radiology, selected procedures, 30 day post-hospitalisation benefit and casualty ward treatment. The Authorisation Centre needs to be contacted at least 48 hours before admission for a non-emergency or planned procedure to obtain an authorisation number. In an emergency, or if you need to be admitted sooner than planned, you must obtain an authorisation number from the Authorisation Centre within two working days after admission. If you are unable to contact the Authorisation Centre yourself, then your doctor or a family member or the hospital can contact us on your behalf. Failure to obtain pre-authorisation for a planned event or authorisation on the first working day after an emergency event will mean that you are liable for a penalty of R1 000 or your treatment may not be covered. We need the following information to authorise your treatment: ~ Membership number ~ Member or beneficiary date of birth ~ Reason for admission and applicable tariff codes for the proposed treatment ~ Date of admission and the proposed date of operation ~ The referring doctor s name, his/ her telephone and practice numbers, if available ~ Name of the hospital with telephone and practice numbers if available ~ For a CT scan, MRI procedure, etc., the name of the radiological practice is also required. Contact number: (Monday to Thursday 08h30 17h00 and Friday 09h00 17h00) authorisations@fedhealth.co.za How to claim In most cases your healthcare professional will submit your claim on your behalf directly to Fedhealth via Electronic Data Interchange (EDI). In this case, please do not also submit this claim. If the healthcare professional does not submit a claim on your behalf, or if you have settled the account yourself, all you need to do is submit the proof of payment together with the claim and make sure the account reflects your membership number. Forward this to Fedhealth either by mail, fax or for fast and effective processing. Postal address: Private Bag X3045, Randburg, 2125 Fax number: (011) claims@fedhealth.co.za Should your healthcare professional inform you that the claim has not been paid, you can contact the Fedhealth Customer Contact Centre to enquire on the status of the claim on or you can check your claims status on the website. See Electronic Communications Services below. If you have paid the healthcare professional, Fedhealth will refund you directly into your bank account. ICD10 coding: It s important to remember that all claims to a medical scheme must contain an ICD10 code. Claims without an ICD10 code will be rejected. Please ensure that the Scheme is in possession of your updated banking details for refund purposes. To update your banking details, please phone the Fedhealth Customer Contact Centre on Only claims received within four months of treatment will be processed. Any claims received after this time will be considered stale. These claims will be processed for tax certificate purposes only. Claims against the Road Accident Fund If you have been involved in a car accident, you may have a claim against the Road Accident Fund. Certain procedures will apply before claims will be paid by the Scheme. Please contact the MVA/ Third Party department at Fedhealth for further details. Telephone number: (011) / 6 / 9 Fax number: (011) Postal address: P O Box Sandton 2146 Who can be registered as a dependant? Your spouse, partner, children or other family members who rely on you for financial care and support may be registered as your dependants. Fedhealth will charge the child rate for your child dependants until they turn 27. However, the child needs to be a full-time student, either living at home or in a residential situation at a tertiary education institution. If your child is not a student, Fedhealth needs confirmation that they are living at home, unmarried, and not in receipt of a regular income greater than the maximum social pension. Adding a newborn baby to your membership As a Fedhealth member you are given 30 days to register a newborn baby or individual underwriting may apply. You are therefore required to complete a Member Record Amendment Form. A copy of the baby s birth certificate or notification of birth from the hospital must be attached when submitting the form to the Scheme. If you belong to an employer group, the salary department also needs to be updated with a new dependant s contribution due for the next month as Fedhealth does not charge for the month in which a baby is born. ID numbers are required to be submitted to the Scheme as soon as the baby is registered. New membership cards will automatically be generated and posted to you. Adding a dependant to your membership Please check your company subsidy with regards to additional dependants if you belong to an employer group. A Member Record Amendment Form form needs to be completed. New membership cards will automatically be generated and posted to you. Should you wish to add a dependant that falls into one of the following categories, please take note of the additional information required in order to proceed with applying for their membership: Your biological or adopted child over the age of 21 years Proof of registration from a full time tertiary institution for the current year if a full time student, or an affidavit for the dependant confirming residency, marital status, employment status and income Your adopted child under the age of 21 years Proof of legal adoption Your foster child Legal documents pertaining to the foster child

9 important user tips continued A parent or grandparent of the principal member An affidavit confirming residency, marital status, employment status and income A sibling, grandchild, nephew or niece An affidavit confirming residency, employment, income and marital status of child and both parents. A divorced spouse A copy of the divorce decree confirming that the principal member is responsible for the medical aid contribution payments. Removing a dependant from your membership In order to remove a dependant you are required to complete a Member Record Amendment Form. This form must be processed and stamped by the HR Department and forwarded to the Scheme if you belong to an employer group. Leaving the Scheme Should you wish to resign from Fedhealth, we require three month s written notice. Please note that as Fedhealth is an arrears billing scheme, your last contribution will be deducted by the 3rd of the month following your last day of membership. Fraud management You can help combat fraud by anonymously contacting our fraud hotline if you become aware of any healthcare professional or member abusing the system. Fraud Hotline: Electronic communication services Managing your medical aid fast and effectively. Real-time electronic communication Fedhealth will and SMS a claim status to you showing claims that have been received and processed. Please ensure that Fedhealth has your correct cell number and address by calling the Fedhealth Customer Contact Centre on Website You can also view a full update of your benefit and claim status by registering on the Fedhealth website. You will have immediate access to all your personal information. Fedhealth website: Credit control Contributions to Fedhealth are paid monthly in arrears and should be received by the Scheme by the 3rd of the following month. Fedhealth s banking details Account name: Fedhealth Medical Scheme Bank: Nedbank Branch code: Account number:

10 contact us medscheme client service centres For personal assistance, visit one of the following Medscheme Client Service Centres These branches are open Monday to Friday 08h30 16h00 Bloemfontein - Suite 13, Westdene Office Park, Pres. Reitz Avenue, Westdene Cape Town 15th Floor, Atterbury House, 9 Riebeek Street Durban 3rd Floor, 67 Old Fort Road Port Elizabeth 1st Floor, Block 6, Greenacres Office Park, 2nd Avenue, Newton Park Pretoria Ground Floor, Benstra Building, 473B Church Street, Arcadia Roodepoort 37 Conrad Street, Florida North Vereeniging 2nd Floor, 36 Merriman Avenue Fedhealth Customer Contact Centre Monday to Thursday 08h30 17h00 Friday 09h00 17h00 Tel: fedhealth@medscheme.co.za Web: Postal address: Private Bag X3045, Randburg 2125 Hospital Authorisation Centre Monday to Thursday 08h30 17h00 Friday 09h00 17h00 Tel: authorisations@fedhealth.co.za Web: Europ Assistance Tel: Aid for AIDS Monday to Friday 08h00 17h00 Tel: Fax: afa@afadm.co.za Web: SMS (call me): Chronic Medicine Management Monday to Friday 08h30 17h00 Tel: Fax: / 80 cmm@medscheme.co.za Web: Postal address: P O Box 38632, Pinelands, 7430 Disease Management Monday to Friday 08h30 17h00 Tel: diseasemanagement@medscheme.co.za Web: Fedhealth Baby Monday to Friday 08h00 17h00 Tel: info@babyhealth.co.za Web: Fraud Hotline Tel: ICAS (Trauma Counselling) Tel: MVA Third Party Recovery Department Monday to Friday 08h00 16h00 Tel: (011) / 6/ 9 Fax: (011) Postal address: MVA Third Party Recovery Department P O Box , Sandton, 2146 Oncology Disease Management Monday to Friday 08h30 17h00 Tel: Fax: (021) cancerinfo@medscheme.co.za Web: Postal address: P O Box 38632, Pinelands, 7430 Disclaimer: This document is a summary for information purposes only and does not supersede the Rules of the Scheme. In the event of any discrepancy between this summary and the Rules, the Rules will prevail. A copy of the Rules is available on request.