Pre-authorisations

Pre-authorisation for hospital admissions and procedures in hospital

Authorisation should be obtained from the Fund before any hospital procedures or diagnostic investigations are performed. Pre-authorisation protocols ensure that requested procedures are covered by the Fund and membership is verified.

Pre-authorisation is required at least 48 hours before the admission.

Any treatment that falls outside the scope of the pre-authorised treatment will require further authorisation from the Fund.

In case of admission to hospital in emergencies, the Fund should be advised of the admission within 48 hours after the admission.

Note that the granting of pre-authorisation does not guarantee full payment of your claims.

Annexure C of the Transmed rules provides a comprehensive list of procedures that are excluded from payment.

How to obtain pre-authorisation

  • 1
    Pre-authorisation can be obtained by the member, the healthcare provider or the hospital.

    The following information is required

    ID number Membership number Name of hospital/practice number Name of patient Date of birth Name of service provider (e.g. doctor, specialist, etc.) and his/her practice number ICD-10 diagnosis code(s) Procedure to be performed (CPT-4 or tariff codes) Date of admission Name and telephone number of caller Does the treating doctor charge medical aid rates
  • 2
    If pre-authorisation is granted, an authorisation number will be provided
  • 3
    If you are a web user, your authorisation will be visible on the website when you login
  • 4
    Give the authorisation number to your healthcare provider and hospital

Chronic medication pre-authorisations

Chronic medication is medication taken for three months or longer for a life-threating condition, or to relieve symptoms of a condition that is on-going and could seriously debilitate your health. Examples are hypertension, diabetes, asthma and epilepsy.

Chronic medication is subject to formularies, clinical protocols and reference pricing.

A chronic condition is a condition that requires ongoing long-term or continuous medical treatment. All Transmed's plans provide cover for the 26 PMB chronic conditions including HIV/AIDS.

The legislated treatment for chronic illnesses include the diagnosis, medical management and treatment. Examples of chronic conditions include diabetes, asthma and high blood pressure (hypertension).

List of conditions covered

Chronic conditions are subject to pre-authorisation by the Medicine Risk Management Department

Please view our Medicine Risk Management Programme.

Telephonic application process for chronic medication

(All plans excluding Link plan)
  • 1
    Ask your healthcare provider or pharmacist
  • 2
    The consultant will obtain all relevant details about your application from your healthcare provider.
  • 3
    The application will be processed.
  • 4
    Your healthcare provider will supply you with your medication or a prescription which you can take to your pharmacy.
  • 5
    A copy of the authorisation letter will be issued to you.
  • 6
    An authorisation period will be indicated for each approved medication.

Written application process for chronic medication

(All plans excluding Link plan)
  • 1
    Download the application form
    Chronic Medicine Programme application form
  • 2
    create Complete the applicant's section of the application form.
  • 3
    Ask your healthcare provider to complete the practitioner's section of the form.
  • 4
    Check that the application form is completed and that it is accompanied by supporting test results or specialist reports.
  • 5
    Submit the completed application form to the Chronic Medicine Programme.
    Email
    [email protected]
    print Fax
    0800 122 236
    OR
    Post
    Chronic Medicine Programme
    PO Box 15079
    Vlaeberg
    8018
  • 6
    The application will be processed upon receipt of the completed form.
  • 7
    An authorisation period will be indicated for each approved medication.
  • 8
    A copy of the authorisation letter will be posted or emailed to you upon request.

Link plan

Please contact Universal Healthcare

icps