Hospital admissions and emergencies

In certain instances you will not have to pay co-payments or deductibles

The Scheme will still pay the Prescribed Minimum Benefit claims in full if you have involuntarily obtained the services from a provider other than a Designated Service Provider, if:

• it was an emergency, for hospital admissions
• the service was not available from the Designated Service Provider or would not have been provided without unreasonable delay; or
• there was no Designated Service Provider within a reasonable distance from your place of business or residence.

Before you go to hospital for any planned procedure, you must:

• See your doctor who will decide if it is necessary for you to be admitted
• Make sure you know how the account from your admitting doctor will be covered
• Choose which hospital you want to be admitted to
• Find out how we cover other Healthcare Professionals, for example your anaesthetist
• Your Retail Medical Scheme membership number
• When you'll be admitted to hospital and how long you'll stay
• Your treating doctor's name and practice number
• The name and practice number of the hospital or day clinic
• The date of procedure
• Your diagnosis (ask your doctor for the ICD-10 diagnosis code)

The procedure name and code, if available (ask your doctor for the RPL procedure codes)

You must preauthorise at least 48 hours before your planned hospital admission, except in emergencies.

A 30% non-notification penalty fee will apply if the member does not preauthorize their admission. Therefore, 70% of the hospital and related accounts will be covered and you will be responsible to pay the difference.

Where the Scheme has appointed a Designated Service Provider (DSP), non PMB's will only be paid in full if the services are obtained at the DSP.