6. Pre-Authorisation

6.1 What is pre-authorisation (PAR)?
Pre-authorisation (PAR) is the prior approval of any planned admission to a hospital, including an associated treatment or procedure (including a dental procedure) performed during hospitalisation.

MRI/CT-scans and radio-isotope studies, whether during hospitalisation or not, also require specific pre-authorisation as well as certain endoscopic procedures. However, the following procedures do NOT require a PAR, and benefits in respect thereof will be paid from your Option’s radiology benefits:

• Dexa scans
• CT bone mineral density studies
  

If you are unsure if the procedure falls within the above categories, it is recommended that you call the Pre-Authorisation Centre for advice.

NOTE: A PAR is not a guarantee of payment of a claim. Payment is at all times subject to available benefits and co-payments may apply (full detail in Summaries of Benefits.

6.2 When must I apply for a pre-authorisation reference number (PAR)?
Application for a PAR should be made as soon as possible, preferably upon confirmation of admission by your doctor.

However, it is recommended that application be made at least three working days ahead of a planned procedure, in case more information is required from your doctor. In the event of an emergency admission to hospital over a weekend or at night, you may apply for a PAR from the Preauthorisation Centre within two working days of the admission or scan. In the case of pregnancy, it is recommended that pre-authorisation be obtained by the 28th week.

6.3 How do I contact the Pre-authorisation Centre to obtain a PAR?
Send an e-mail to: authorisations@selfmed.co.za,
fax 0860 467 727 or telephone 0860 10 4974.

6.4 What information should I furnish when applying for a PAR?

• Membership number and dependant code.
  
• Patient’s full name and date of birth.
  
• Date of admission PLUS the date of procedure (This is particularly important, as we do not routinely authorise preoperative procedures the day prior to planned surgery – this must be applied for and motivated).
  
• Surname and initials of attending doctor or service provider and practice number.
  
• Name and telephone number of admitting doctor or in the case of MRI- and CT-scans, the details of the radiologist.
  
• Name of hospital to which the patient will be admitted.
  
• The reason for the admission to hospital or the planned diagnostic procedure.
  
• To assist with your PAR-application, ask your doctor for a full description of:
  – The diagnosis, and
  – the planned procedure as well as the procedural codes he/she intends to use.

6.6 Treatment of out-patients at the casualty department of a hospital

Please note that visits to the doctor at a hospital’s out-patient or casualty department will not always be funded from your hospital benefit. For this reason, some hospitals may require that you pay cash for these visits. In this event, you may send the account to the Scheme and you will be refunded according to your day-to-day, out-of-hospital benefits.