7. Managed Healthcare

Managed healthcare is defined as any effort to promote the rational, cost-effective and appropriate use of healthcare resources. The philosophy of the Scheme is to work with members and service providers in achieving these aims.

7.1 Protocol
The Scheme’s managed healthcare provider uses funding guidelines and protocols in respect of certain services and supplies for which the Scheme allows benefits. Beneficiaries will only qualify for benefits in respect of those services and supplies; if the guidelines and protocols have been complied with.

The Scheme or its managed healthcare provider reserves the right to request a second opinion, at the Scheme’s cost and with a doctor nominated by the Scheme, in respect of any elective hospital procedure. A fitness report will also be required in respect of any requests for spinal- or joint surgery.

The Scheme or its managed healthcare provider may also, in its discretion, limit the cost of any laparoscopic surgery to the cost of the equivalent conventional (open) surgery.

7.2 Disease Management
Disease Management is a holistic approach that focuses on the patient’s disease, using all the cost elements involved. The intervention takes place by means of patient counselling and education, behaviour modification, therapeutic guidelines, incentives and penalties and case management.

7.2.1 Oncology Benefit Management
It is important that, prior to starting active treatment for cancer, you are registered on the Oncology Disease Management programme.

7.2.1.1 How do you register?

In order to be registered, your treating doctor needs to complete a treatment plan and forward this to the clinical team, as all oncology treatment is subject to pre-authorisation and case management. If you are given cancer-related treatment and your treatment has not been pre-authorised by the Oncology Disease Management Programme, no oncology benefit will be paid by the Scheme. Note that members on the MEDXXI and Selfsure options are required to make use of the Scheme’s preferred provider oncology network.

Once the Oncology Disease Management team receives your disease information, treatment plan and your membership details, your proposed treatment will be captured. The treatment plan is then reviewed, and if necessary, a member of the clinical team will contact your doctor to discuss treatment alternatives. An authorisation will be sent to your doctor after the assessment and approval of the treatment plan. You will also be issued with an authorisation letter.

Please ensure that your doctor advises the Oncology Disease Management team of any change in your treatment, as your authorisation will then need to be re-assessed and updated.

NOTE: In addition to authorisation from the Oncology Disease Management team, you will need to get pre-authorisation from the Hospital Management department for any hospitalisation, specialised radiology, step-down facilities and stoma therapy

7.2.1.2 Who does your treating doctor contact to register your treatment?
Phone 0860 104 974, e-mail oncology@selfmed.co.za or send a fax to 0860 467 727.

7.2.1.3 Do any limits apply to Oncology Benefits

Yes. The Scheme allows an insured benefit for the oncology treatment, including the associated pathology and radiology, during the active stage of the disease but subject to an overall annual limit. If hospitalisation is required as part of the oncology treatment such hospital costs will not accumulate to the oncology limit.

7.2.2 HIV/AIDS
Specific benefits are available with regard to antiretroviral therapy, related medicine and pathology tests and will be handled and managed in the strictest confidence, when members register on the Scheme’s HIV/AIDS Management Programme. Support and counselling is available to the relevant member and family, if required. Any member or dependant who has tested positive for HIV must join the HIV/AIDS Management Programme in order to access benefits.

Please refer to your Option’s Summary of Benefits for more information.
Contact numbers are reflected at the back of this guide.

7.3 Breast reconstruction
Benefits are allowed in respect of reconstructive surgery after mastectomy of proven breast cancer. Benefits will be paid once only for full reconstruction by whichever method, as well as for reduction surgery on the unaffected side for symmetry, where indicated, as per motivation. Only complications of a true medical nature will be considered for benefits and not failed cosmesis.

7.4 Organ transplants and dialysis
Benefits in respect of organ transplants and dialysis are subject to treatment forming part of a Case Management Programme.

Benefits are allowed in respect of kidney dialysis and the following organ transplants: heart-, lung-, heart-and-lung, bonemarrow-, kidney- and liver transplants.

Benefits are further subject to the recipient being a beneficiary of the Scheme in which case limited benefits will be applicable.

Please refer to the Summary of Benefits for more information about the benefits that your Option offers.

7.5 Ambulance services ER24

7.5.1 Who should I call for ambulance services?
ER24 is the Scheme’s Preferred Provider for any ambulance services. If services are not rendered by (or through the intervention of) ER24, benefits will be limited to a specified maximum (please refer to the Summaries of Benefits for details).

7.5.2 How do I contact ER24?
For clinical advice or to request medical emergency transport, phone 084 124 if you are in the RSA. For claims enquiries phone 011 319 6580.

7.5.3 How much time do I have to inform ER24 that I have made use
of another ambulance service as a result of an emergency?
In the event of an emergency, you should inform them within 24 hours of the date on which the service was rendered to qualify for unlimited benefits.
Note: The services of this preferred provider are only available in the RSA, Swaziland and Lesotho.
Note: If you need to contact ER24 from one of the above neighbouring countries, their contact number changes to: 011 541 1218.