You are on page 1of 5

Sent Date 03/07/2013

DR L MBETSHU Email hospitalauths@gems.gov.za


PO BOX 5353
GREENFIELDS, EAST LONDON Facsimile 0861 004 367
5208 Website www.gems.gov.za
Telephone 0860 004 367

Approval/Partial Approval of Request

Authorisation Number 71099262 Patient MR BEKUHLANGA NXUSANI


Medical Aid GEMS Medical Aid Number 001014835/01

Option EMERALD Admission Number n/a


Admission Date 04/07/2013 Approved Length of stay 0.0
Expected Discharge Date 04/07/2013

Place of Service ST JAMES HOSPITAL

Accommodation
Accommodation Level From To

Day case 04/07/2013 AM 04/07/2013 PM

Code/s Status Role Type Code Description


Approve Reason for Admission CPT 66983
Associated Diagnosis ICD H25.0
Approve Additional NRPL 3047
Approve Additional NRPL 3201
Additional ICD H17.0
Additional ICD H40.1
Approve Additional NRPL 0201
Authorisation Number 71099262 Patient MR BEKUHLANGA NXUSANI
Medical Aid GEMS Medical Aid Number 001014835/01

Code/s Status Role Type Code Description


Approve Additional NRPL 3097
Approve Additional NRPL 3049
Approve Additional NRPL 3121
Intraocular Lens (IOL): Benefits will be subject to the relevant internal prosthesis benefits up to a maximum
of R2500.00 per lens or subject to the stipulated intraocular lens limit. The member will be liable for the
balance of the cost if a more expensive type of IOL used.Ø Approve the request for either a local and
international corneal graft up to specified benefit limit of R15 000, 00. Ø Advise caller to apply for ex
gratia for corneal grafts exceeding the limit.

Managed Care Notes


AMNIOTIC MEMBRANE TRANSPLANT (AMT). Authorisation dependent on specific clinical motivation. If approved,
only AmnioVis will be funded; subject to available prosthesis benefit. Note that first line (primary or
adjunctive) therapy is excluded from benefits.
CORNEAL GRAFTS. Subject to available benefits. Post corneal transplant corrective surgery will be considered
once only for benefits subject to specific clinical criteria. No benefits for InfraLase Enabled
Keratoplasty.
DAY CASE ADMISSION: This admission will only be funded by the scheme as a day case admission. If the patient
is required to stay overnight, a clinical motivation may be submitted for consideration.
INTRAOCULAR LENS (IOL). Lens subject to the prosthesis benefits up to a maximum of R2 500 per lens. The
member will be liable for the balance of the cost if a more expensive type of IOL is used. Standard monofocal
intraocular lens implant is considered to be PMB level of care.
Authorisation Number 71099262 Patient MR BEKUHLANGA NXUSANI
Medical Aid GEMS Medical Aid Number 001014835/01

Scheme Benefit Notes


**TAKE NOTE: This authorisation is only valid for the specified member, accommodation level and code/s, based
on the information provided at time of request. Authorisation is dependent on active membership, benefit
sub-limits and available benefits at date of service. It is not a guarantee of payment. It is essential to
contact the managed healthcare agent in the event of changes to the date of service, length of stay, level of
care or scope of this authorisation request. Please note that should the treatment extend beyond the scope of
authorisation and an appropriate clinical motivation is not received, the Scheme/Fund may decline further
funding. All benefits, including consultations will be reimbursed at Scheme Rate or Negotiated Tariff.
*SCHEME RATE: All benefits including consultations will be reimbursed at the current Scheme tariff.
ACQUIRED IMMUNE DEFICIENCY SYNDROME and RELATED ILLNESS:Registration and compliance with the HIV Management
Programme is required. Limited to Prescribed Minimum Benefit protocols and compliance with the programme.
Includes one consultation for diagnosed and initial counselling
ADVANCED RADIOLOGY: Specific authorisation (in addition to hospital authorisation) required for Angiography,
CT scans,MDCT,Coronary Angiography,MUGA / PET /MRI scans and Radio-Isotope studies. Subject to managed care
protocols. Shared limit with out of hospital: R15 907 per family per annum.
ALCOHOLISM and DRUG DEPENDANCE: Limited to Prescribed Minimum Benefit and pre-authorisation. Managed care
protocols and use of DSP required.
ALLIED HEALTH SERVICES: Shared limit with out of hospital Allied Health Services of R1 173 per family
ALTERNATIVES TO HOSPITALIZATION: (Hospice, Sub Acute Facilities, Nurse Practitioners and Nursing Agencies).
Subject to prior authorisation and managed care protocols. Excludes frail care and recuperative holidays.
Includes physical rehabilitation for approved conditions and post surgical discharge home nursing.
AMBULANCE/EMERGENCY ASSISTANCE: Unlimited when in line with appointed Designated Service Provider protocols.
Includes road and air.
APPEALS : Hospital Benefit Management Appeal: To appeal a decision of decline / partial decline, a letter of
motivation may be submitted via e-mail to hospitalauths@gems.gov.za or via fax to 0861 00 4367
BLOOD,BLOOD EQUIVALENTS and PRODUCTS: Unlimited when preauthorisation, managed care protocols and processes is
obtained. Includes cost of blood, blood equivalents, blood products , Erythropoietin and transport of such.
BREAST REDUCTION BENEFIT : Pre-authorisation, managed care protocols and processes required.
CHRONIC DISEASE MANAGEMENT : All benefits for chronic diseases require registration on the disease management
programme and protocols
CIRCUMCISION : Global fee of R1 068 which includes all post-op care within a month of procedure. Limit applies
to all related costs (consult, medicine etc). Subject to pre auth. Out of hospital only.
CORNEAL GRAFTS. Subject to available benefits. Post corneal transplant corrective surgery will be considered
once only for benefits subject to specific clinical criteria. No benefits for InfraLase Enabled Keratoplasty.
COSMETIC SURGERY: Not covered by Scheme.
DENTAL : Conservative, Restorative and Special Dentistry (In and Out of hospital): In-hospital benefit for
professional fees of R3 696 not to exceed R1 760 per beneficiary and specialized dentistry subject to
Prescribed Minimum Benefits only. Hospital and anaesthetist only paid from hospital benefits. No benefits for
Osseo-integrated implants, implant-related procedures and orthognathic surgery. 200% of scheme rate for
treatment of bony impactions of third molars under conscious sedation in doctor's rooms. Lingual and labial
frenectomies under general anesthesia for beneficiaries under the age of 8 years, subject to managed
healthcare programme and pre-authorisation. All general anaesthetic and conscious sedation for dentistry is
subject to prior authorisation. In-hospital benefits for beneficiaries under the age of 8, severe trauma and
impacted third molars. Lingual and labial frenectomies under general anaesthesia for beneficiaries under the
age of 8 years, subject to managed healthcare programme and pre-authorisation. All services subject to
pre-authorisation.
DESIGNATED SERVICE PROVIDER : For in-hospital PMBs, the designated service provider is the State. Use of
non-DSP will attract a co-payment. Where PMB services are not available from a DSP, the member should call the
GEMS call centre number 0860 004367 to discuss alternatives for approval by the Scheme.
EMERGENCY SERVICES (CASUALTY) : Limited to PMB's ( emergency medical condition as defined in the rules).
Subject to use of registered emergency facility. Subject to authorisation.
FAMILY BENEFITS: All benefits and sub limits are calculated per family per year unless otherwise specified.
FOLATENG WARDS: Please note that Private Wards available for use at selected Provincial Hospitals. Please
contact the Client Service Centre for more detail, 0860004367.
GENERAL PRACTITIONER NETWORK EXTENDED BENEFIT: Extended benefit for beneficiaries with chronic conditions
registered on Disease Management Programme. Payable from Risk. One additional GP consultation at a DSP/Network
provider once PMSA and Block Benefit is exhausted. Subject to pre-authorisation and managed care protocols
HEADACHE CLINICS/STRESS RELIEF CLINICS - Not covered by Scheme.
INFERTILITY: Limited to Prescribed Minimum Benefit and Designated Service Provider.
INTERVERTEBRAL DISC PROSTHESIS: No benefits for surgery where non-covered / restricted items are used i.e.
any other artificial disk replacement, unless this procedure is pertinently pre-authorised and meets funding
criteria. If it transpires that such prosthesis has been used, the authorisation for the surgery will be
revoked retrospectively. Bone Cement paid from in hospital benefit.
INTRAOCULAR LENS (IOL). Lens subject to the prosthesis benefits up to a maximum of R2 500 per lens. The member
Authorisation Number71099262 Patient MR BEKUHLANGA NXUSANI
Medical Aid GEMS Medical Aid Number 001014835/01
will be liable for the balance of the cost if a more expensive type of IOL is used. Standard monofocal
intraocular lens implant is considered to be PMB level of care
KYPHOPLASTY/VERTEBROPLASTY: Subject to Kyphon Accreditation - This will only be funded for accredited
providers, subject to internal prosthesis benefit limits.Bone Cement paid from in hospital benefit . Non PMB.
MATERNITY : Authorisation required AT LEAST 48 hours prior to admission to hospital ( except in case of
emergency). Failure to do so will result in a R1000 co-payment per admission. Home birth subject to sub-limit
of R7 755 per beneficiary per annum payable at Scheme rate only.
MEDICAL TECHNOLOGIST: Limited to pre-authorisation and case management.
MEDICAL and SURGICAL APPLIANCES and EXTERNAL PROSTHESIS: Includes Hearing Aids,Wheelchairs,Oxygen
Cylinders,Nebulizers,Glucometers,Colostomy Kits, Diabetic equipment and external prosthesis. Shared limit with
in-hospital internal prostheses of R30 068 per family per annum. Sub limit of R11 732 for medical and surgical
appliances per family per annum. Subject to pre-authorisation and managed care protocols. Scheme has the right
to obtain competitive quotes. Subject to Prescribed Minimum Benefits.
MENTAL HEALTH : In-Hospital: Limited to Prescribed Minimum Benefit and pre-authorisation: R13 256 per family.
A maximum of 3 days hospitalisation for admissions by a General Practitioner. Further hospitalisation requires
motivation to the Managed Care program. Scheme rates apply. Benefit includes accommodation, use of operating
theatres and hospital equipment, medicine, pharmaceuticals, surgical items,procedures,consultations / visits,
assessments,therapy,treatment and / or counselling performed by General Practitioners, Psychiatrists,
Psychologists,Psychometrists or Registered Counsellors.
NEW BORN REGISTRATION: Please note that all newborn babies have to be registered within 60 days of birth to
enjoy benefits from date of birth. Failing this, benefits will only be applicable from the first day of the
first month after registration. Accounts for babies not registered on the scheme, will not be reimbursed
notwithstanding the maternity event being authorised.
NON-COVERED LIST: Certain items, including medicine, are excluded from benefits unless specifically
pre-authorised. This includes certain high cost items. Please check with the hospital / treating provider that
specialized items have been authorised before use.
ONCOLOGY : Limited to Prescribed Minimum Benefits and pre-authorisation.R265 134per family. Biologicals &
similar specialised medicine sublimit of R180 366 per family . MPL applies. Includes cost of pathology,
related basic radiology above/advanced radiology benefit, medical technologists and oncology medicines. Use of
registered facility and managed care processes and policies.
ONE DAY NON PMB ADMISSION: Pre-authorisation required. R12 623 per beneficiary. Relevant to Hospital Services
rendered on same day for non Prescribed Minimum Benefit conditions. Member will be liable for cost in excess
of the available benefit limit. Prorating of limits not applicable, full benefit irrespective of date of
registration.
OPTICAL :Sub limit of R1 760 per beneficiary every second year and annual limit of R3 519 per family. Frames
not to exceed R1 089 . Professional fees, spectacle lenses, lens additions and contact lenses are subject to
Optical Managed Care Programme. Refractive surgery and eye examinations will be reimbursed from this benefit
only. All tinted lenses and photochromic are excluded.
ORGAN and TISSUE TRANSPLANT: Limited to Prescribed Minimum Benefit and pre-authorisation. R441 886 per
beneficiary per annum. Sub limit of R15 000 per beneficiary per annum for corneal grafts Imported corneal
grafts subject to managed care protocols.Includes harvesting of the organ/s or haemopoietic stem cells and
transplant. Includes radiology and pathology for organ transplants and immunosuppressants. Organ harvesting is
limited to the Republic of South Africa except for cornea tissue. Subject to clinical guidelines used in
Public facilities.
OVERALL LIMIT: Hospitalisation benefit is unlimited but sub-limits apply as specified
PELVIC FLOOR SYSTEMS AND MESH WITH GYNAECOLOGICAL SURGERY. The cost of evidence based pelvic floor repair
systems and mesh will be funded up to R3 300, subject to prosthesis benefits and limits. Clinical motivation
and specific motivation required for more expensive mesh. Standard Transvaginal Tape (TVT) is subject to
available prosthesis limits. No benefits for absorbable adhesion barriers
PENDING AUTHORISATION. The request for an emergency admission was received without any supporting clinical
information. Please forward clinical information so that this request can be reviewed
PHYSIOTHERAPY: In Hospital:R3 575 per beneficiary per year, Out of Hospital subject to day to day block
benefit limit of R3 308 per beneficiary and R6 616 per family per annum. In Hospital benefits subject to
relevant Managed Care programme and interventions and to its prior authorisation
POST CATARACT SURGERY: Optical PMB entitlement will be limited to the cost of bifocal lens, not exceeding R842
for both lens and frame with a sublimit of R167 for the frame
PRE-AUTHORIZATION:All benefits require pre-authorisation at least 48 hours for planned admissions and within
one working day after emergency admissions. Failure to obtain such pre-authorisation may result in, a
co-payment of R1000 per admission being applied. Clinical protocols still apply even if pre-authorisation is
requested late. Benefits are only available if membership is active at date of service.
PRESCRIBED MINIMUM BENEFITS: 100% of cost in public hospitals and/or Designated Service Provider subject to
managed care protocols.
PRESCRIBED MINIMUM BENEFITS: Your condition is classified as a PMB. The DSP is the State. If the DSP is not
available or accessible, please contact the GEMS call centre at 0860 00 4367 to discuss alternatives.
Voluntary use of a non-DSP may result in a co-payment for both provider and hospital claims. The co-payment
will be the difference between the rate that the DSP would charge and what the non-DSP hospital and/or
Authorisation Number 71099262 Patient MR BEKUHLANGA NXUSANI
Medical Aid GEMS Medical Aid Number 001014835/01
provider charges.
PREVENTATIVE CARE SERVICE: Payable from risk. Benefit roll over three calendar years and screening tests may
only be done once in the three year period. Pap smears including liquid based cytology may be done annually.
This benefit includes: Serum Cholesterol, Bone Density Scan, Pap smear, prostate specific antigen, glaucoma
screening, serum glucose and mammogram and other screening according to evidence based standard practice.
PRO-RATA: All benefits and sub limits are calculated Prorata from date of joining. For example: If you join on
1 July, you would only qualify for 6 months' benefits (July to December). As 6 months equal half of the year,
you would only have half the benefits available for the rest of the year.
PROSTHESIS: Internal (Shared benefit with medical and surgical appliances and external prosthesis): R30 068
per family per annum. The Scheme reserves the right to obtain comparative quotes. Subject to relevant Managed
Care programme and interventions and to its prior authorisation. The benefit covers prosthesis and internal
devices (surgically implanted), including al temporary or permanent devices used to assist with the guidance,
alignment or delivery of these internal prostheses devices. Other material required and used in the insertion
of a prosthesis, will be funded from the available prosthesis benefit. Bone Cement paid from in hospital
benefit
RADIOLOGY (BASIC) and PATHOLOGY: General In-Patient: Unlimited.
RENAL DIALYSIS (CHRONIC): Limited to Prescribed Minimum Benefit. Benefit limit: R189 376 per beneficiary per
annum for chronic dialysis. Includes radiology and pathology for chronic renal dialysis. Managed Care
programme and interventions requires pre-authorisation.
RENAL DIALYSIS: (ACUTE) Limited to Prescribed Minimum Benefit and pre-authorisation. Limited to and included
in the Hospitalisation benefit.
SURGICAL PROCEDURES & MAXILLO FACIAL SURGERY: In-Hospital Benefit: Unlimited when pre-authorisation has been
done.
TTO's (Medicine after discharge): Limited to 7 days supply. Limited to acute illness benefit.
The medical aid scheme only pays the agreed tariff
WILLFULL SELF INFLICTED ILLNESS OR INJURY: Limited to Prescribed Minimum Benefits (two nights, three days)
only.