(2192021123313 PM) Sasolmed Member Guide 2021 - Updated 15 Feb

MEMBER GUIDE 2021
OWN YOUR TOMORROW

CONTENTS
1. WELCOME 4 4. CLAIMING MADE EASY 22
• What does Sasolmed offer me? • How should I submit my accounts?
• What are my responsibilities as a member? • How can I help speed up my claims processing?
• What is the role of the administrator? • When can I expect payment?
• Should I pay the healthcare provider directly?
2. NEED HELP? GET IN TOUCH 7
• How will I know what was paid?
• Important contact details • How do I submit an ex gratia claim?
• Sasolmed ‘SasChat’ and Webchat instant messaging
service 5. SELECTING A PREFERRED GENERAL
• Walk-in centres and Client Liaison Consultants (CLCs) PRACTITIONER (PGP) 26
• Website Member Zone functionality • Why do I need to choose a PGP?
• Electronic Health Record (EHR) • How do I select a PGP?
• What if my specific PGP is not available?
3. MEMBERSHIP 17
• What if different members of my family prefer
• Who is eligible for membership? different PGPs?
• Who can be registered as dependants? • What if we are on holiday and cannot visit our
• Who is not eligible for membership? PGP?
• How do I apply for membership or change my • What if we have an emergency?
membership details? • What if I voluntarily consult a non-PGP?
• How are my membership contributions calculated? • Can I change my mind about a PGP?
• What should I do with my membership card? • Who can register an additional PGP and how?
• What waiting periods will apply to new members • What if I need to see a specialist?
or dependants?
6. PREVENTATIVE CARE 31 9. PRESCRIBED MINIMUM BENEFITS (PMBs) 64
• What do the preventative care benefits include? • Why do we have PMBs?
• Why should I go for screening tests? • How do I access PMBs?
• How can Sasolmed help me to stop smoking? • How can healthcare providers ensure payment
of claims for PMBs?
7. MANAGED CARE 34
• Council for Medical Schemes article on PMBs
• What is managed care?
• Medicine Management Programme, including chronic 10. FREQUENTLY ASKED QUESTIONS 69
medicine and Prescribed Minimum Benefits (PMBs) • What are ICD-10 codes?
• Hospital benefit and pre-authorisation • Will I be covered for motor vehicle injuries?
management • What if I need a knee or hip replacement?
• Dental management • What should I know about fraud?
• Optometry management • What is benefit exploitation?
• Back and neck rehabilitation Programme • What if I am unhappy with service received from
(Documentation Based Care [DBC]) Sasolmed?
• Oncology Management Programme • What is included in my member’s portion?
• Weight Management Programme • What are co-payments and how can they be
• YourLife Programme (HIV/AIDS) minimised?
• Mental Health Programme • Why are certain emailed documents password
• Active Disease Risk Management Programme protected?
• Maternity Management Programme
• Paed-IQ BabyLine 11. EXPLANATION OF TERMS 80
8. EMERGENCY MEDICAL SERVICES 60

• What should I do in an emergency situation?
• What else can ER24 offer me? This Member Guide provides you with an overview of your membership, your
• When will my costs or services not be covered? responsibilities as a member of the Scheme, managed care programmes
• When should I call an ambulance? available to you and your dependants, how to submit a claim and other
important information pertaining to your membership of the Scheme. Please
read it in conjunction with your 2021 Benefit and Contribution Schedule,
which can be found at www.sasolmed.co.za.
1
IN THIS CHAPTER
• What does Sasolmed offer me?
WELCOME • What are my responsibilities as

a member?
• What is the role of the

administrator?
Welcome
WHAT DOES SASOLMED OFFER ME?
You never know when you or one of your family members may need medical care, which could cost a substantial amount.
Contact
The following diagram offers an overview of the potential medical expenses that can be incurred during a typical person’s
life.
Membership
THE HEALTHCARE
JOURNEY
Claiming
Joins Scheme Young and healthy; Road accident or sports injury
minimal healthcare
needs
Selecting
a PGP
Preventative
Tonsil surgery or dental Child trauma injury Premature birth Maternity Starts relationship;
care
admissions needs medical cover
for partner
Managed
care
Emergencies
Chronic disease Dread disease Lifestyle diseases Healthy lifestyle becomes Cardiac conditions
such as cancer develop increasingly important or stroke
PMBs
Medical expenses can
arise at any stage of your
life. The Scheme offers
FAQ
different programmes to
Cataract surgery Hip replacement After retirement; Specialised treatment
cater for these life ageing process more for back and neck pain,
events. pronounced to avoid surgery
Terms
Welcome
Sasolmed provides medical cover to you and your dependants • contacting the Scheme before you are admitted to hospital to
for a wide range of medical services, prescribed medicine and pre-authorise your admission;
Contact
medical events, such as hospitalisation and surgery. Sasolmed’s • pre-authorising your chronic conditions and medicine with the
vision is to offer Sasol employees a medical scheme that ensures Scheme;
holistic, integrated and sustainable healthcare that improves the
Membership
• informing the Scheme of any third-party or motor vehicle
health and quality of life of all beneficiaries, through balanced
accident claims or of any payments made to you by the Road
contributions and benefits.
Accident Fund;
WHAT ARE MY RESPONSIBILITIES AS A MEMBER? • filing all your documentation regarding the Scheme so that
Claiming
you can refer to it if necessary, especially tax certificates, as
You can help the Scheme, and yourself, by taking responsibility
the South African Revenue Services (SARS) may require you to
for the following:
produce these even up to ten years later;
Selecting
a PGP
• understanding how the Scheme works and what benefits you • keeping your membership card in a safe place so that no one
are entitled to by reading communication from the Scheme else can use it fraudulently; and
and attending awareness sessions; • most importantly, remembering that your health is ultimately
Preventative
• keeping the Scheme up to date on any changes to your YOUR responsibility; even though the Scheme can help in many
care
membership details; ways, you can play an extremely important part in avoiding or
• checking all accounts from service providers, as well as your managing especially the lifestyle diseases so common and
claims statements from the Scheme to make sure that all your costly nowadays!
Managed
care
details are correct and that your claims have been processed
correctly; this will also help you to quickly spot any false claims WHAT IS THE ROLE OF THE ADMINISTRATOR?
or over-charges against your benefits and to let the Scheme Momentum Health Solutions (Pty) Ltd, or ‘MHS’, is the
Emergencies
know if you notice anything suspicious; administrator of the Scheme. MHS’s efficient and friendly call
• before having any medical procedures, requesting quotes from centre staff, plus a national network of walk-in centres and Client
service providers and submitting these to the Scheme so that Liaison Consultants (CLCs), are available to resolve your everyday
you can find out the difference between what the Scheme will queries about benefits, claims and membership as efficiently as
PMBs
pay and what you will have to pay directly to service providers; possible.
FAQ
OWN YOUR TOMORROW Sasolmed Member Guide 2021 | 6
Terms
2
IN THIS CHAPTER
• Important contact details
• Sasolmed ‘SasChat’ and

Webchat instant messaging
service
NEED HELP?
• Walk-in centres and Client
Liaison Consultants (CLCs)
GET IN TOUCH
• Website Member Zone
functionality
• Electronic Health Record (EHR)

Welcome
IMPORTANT CONTACT DETAILS
Sasolmed Customer Services – 0860 002 134 Hello Doctor
Contact
Free 24-hour telephonic health advice line
Email: enquiries@sasolmed.co.za
Download the Hello Doctor app from Google Play or the Apple
Fax: 0860 665 357 app store or dial *120*1019# and follow the voice prompts to
Membership
Post: Sasolmed Enquiries, PO Box 2109, Bellville 7535 engage with a doctor on call.
Monday to Friday from 08:00 to 17:00 (excluding public holidays)
Pre-authorisations for hospitalisation and all in-hospital
Sasolmed ‘Saschat’ – 060 070 3068 services – 0860 002 134
Claiming
Monday to Friday from 08:00 to 17:00 (excluding public holidays) Monday to Friday from 08:00 to 17:00 (excluding public holidays)
Email: authorisations@sasolmed.co.za
WebChat
Pre-authorisation for alternatives to hospitalisation –
Selecting
Visit www.sasolmed.co.za or download the Sasolmed NEW
a PGP
0860 002 134
application from the App Store to chat with Sasolmed.
Step-down, sub-acute facilities, day clinics, unattached
Walk-in centres operating theatres, physical rehabilitation centres, hospice,
Preventative
palliative care and nursing services.
See addresses and operating hours on page 13.
care
Client Liaison Services (CLC) – 0860 002 134 Email: authorisations@sasolmed.co.za
Call 0860 002 134 for an appointment with a CLC visiting your Pre-authorisation for specialised radiology benefits –
Managed
area, or to book an online consultation with a CLC. 0860 002 134
care
ER24 (Emergency Medical Services) – 084 124 Monday to Friday from 08:00 to 17:00 (excluding public holidays)
Emergencies
24-hour self-help facility – 0860 002 134
Pre-authorisation for blood products, medical
Available 24 hours a day, seven days a week, 365 days a year – appliances, prostheses and devices – 0860 002 134
including weekends, public holidays and after hours.
PMBs
Follow the voice prompts to request membership certificates,
your latest claims statements, tax certificates and other items,
any time of the day or night.
FAQ
Terms
Welcome
Pre-authorisation for chronic conditions and chronic Registration on Active Disease Management Programme
Contact
medication benefits – 0860 002 134 – 0860 002 134
Membership
Email: chronic@sasolmed.co.za Email: adrm@sasolmed.co.za
Pre-authorisation for oncology benefits and medicine – Registration on Mental Health Programme –
0860 002 134 0860 002 134
Claiming
Email: oncology@sasolmed.co.za Email: mentalhealth@sasolmed.co.za
Pre-authorisation for chronic renal dialysis Registration on Weight Management Programme
– 0860 002 134
Selecting
– 0860 002 134
a PGP
Email: renal@sasolmed.co.za Email: weightmanagement@sasolmed.co.za
Preventative
Pre-authorisation for dental services and orthodontics –
Application for Ex Gratia benefits
care
0860 002 134
Monday to Friday from 08:00 to 17:00 (excluding public holidays) Email: exgratia@sasolmed.co.za
Email: dental@sasolmed.co.za (out of hospital) Submission of claims
Managed
care
Email: authorisations@sasolmed.co.za (in hospital)
Email: claims@sasolmed.co.za
Registration for maternity benefits – 0860 002 134 Fax: 0860 665 357
Emergencies
Monday to Friday from 08:00 to 17:00 (excluding public holidays) Post: Sasolmed Claims, PO Box 2109, Bellville 7535
Email: maternity@sasolmed.co.za Claims and enquiries for motor vehicle accidents
(Road Accident Fund) – 0860 002 134
Registration for HIV/AIDS on the YourLife Programme –
0860 002 134 Monday to Friday from 08:00 to 17:00 (excluding public holidays)
PMBs
Monday to Friday from 08:00 to 17:00 (excluding public holidays) Email: MVA@sasolmed.co.za
Email: yourlife@sasolmed.co.za
FAQ
Terms
Welcome
Contact
Membership
Claiming
Selecting
a PGP
Report fraud or suspected fraud (confidential hotline) –
0800 000 436
Preventative
care
Available 24 hours a day, seven days a week, 365 days a year –
including weekends, public holidays and after hours
Email: sasolmed@tip-offs.com
Managed
care
Babyline (Child Health Advice Line) – 0860 666 112
Available 24 hours a day, seven days a week, 365 days a year –
including weekends, public holidays and after hours
Emergencies
Allen Carr (Smoking Cessation Programme) –
0861 100 200
Easyway Clinics – national booking line
PMBs
Website: www.allencarr.co.za
FAQ
Terms
Welcome
SASOLMED ‘SASCHAT’ AND WEBCHAT
Contact
INSTANT MESSAGING SERVICES
Did you know that you can chat with
Membership
Sasolmed via the Sasolmed ‘SasChat’
WhatsApp facility on 060 070 3068, via
the website at www.sasolmed.co.za or by
downloading the Sasolmed NEW mobile
Claiming
application on your smartphone?

Operating hours are from 08:00 to 17:00,
Selecting
a PGP
Monday to Friday.
What are the benefits?
Preventative
• Less costly than a phone call
care
• Shorter turnaround times than emails
What are the features?
Managed
care
• Submit general enquiries about benefits
and claims payments, for example.
• Submit a new account for processing by
Emergencies
attaching a copy of the account to your
message.
• Request documents, such as tax
PMBs
certificates.
• Check your available benefits.
FAQ
Terms
Welcome
Sasolmed (NEW) mobile application
Contact
• Check your info feed • Chat to a call centre agent
• View your interactive membership card • Register on the Maternity Management Programme
Membership
• View your benefits • Register for chronic medication
• View available benefits • Request a membership certificate
• View authorisations
• View your Electronic Health Record (EHR)
Claiming
• View claims
• View underwriting • View and update your profile.
Selecting
• Access the self service features
a PGP
• Search for providers
• Submit documents
Preventative
• View documentation
care
• Edit your profile
• Submit claims
Managed
care
• Access the documents library
• Check your HealthSaver balance (if you have a HealthSaver
Emergencies
account with Momentum)
• Purchase medicine online
PMBs
• Confirm medicine formularies
• Chat to a doctor
FAQ
Terms
Welcome
WALK-IN CENTRES AND CLIENT LIAISON CONSULTATIONS (CLCs)
If you prefer face-to-face assistance, why not visit a Momentum Health Solutions walk-in
centre in your area?
Contact
Alternatively, call 0860 002 134 for a CLC visiting your area or to book an online
consultation with a CLC.
Membership
Operating hours: Monday to Friday from 08:00 to 16:00 (excluding public holidays).
Office Park no. 9
Claiming
Bloemfontein c/o President Reitz and 3 rd Avenues
Bloemfontein
2nd Floor Birkdale House
Selecting
2 River Park Office Park
a PGP
Cape Town
c/o Gloucester and River Lane Roads
Mowbray
201 uMhlanga Ridge Boulevard
Preventative
Durban
Cornubia
care
Block B, Ground Floor Metropolitan Office Park
Port Elizabeth 279 Cape Road, Newton Park
Port Elizabeth
Managed
care
268 West Avenue
Centurion
Centurion
Traduna House
Emergencies
Braamfontein 118 Jorissen Street
Johannesburg
The Marc Building
Sandton 129 Rivonia Road, Sandown
PMBs
Sandton
Grand Palace
Secunda Unit A2, 2302 Heunis Street
FAQ
Secunda
Terms
Welcome
WEBSITE MEMBER ZONE FUNCTIONALITY
Contact
To register on the Sasolmed Member Zone, follow these Using the Sasolmed Member Zone functionality
easy steps: Home
• Visit www.sasolmed.co.za. This provides a snapshot view of your membership and available
Membership
• Select ‘LOGIN’. features. There are also quick links to:
• When choosing a username and password, remember that the • purchase medicine online;
password is case sensitive, i.e. if you have chosen a password • confirm medicine formularies;
that contains a mix of capital and lower case letters, you must • Hello Doctor, to chat to a doctor;
Claiming
always enter the password in the same way. • chat to a call centre agent; and
• Complete the required information and select ‘Create • visit the Multiply website.
Selecting
Account’.
a PGP
Communication
• Upon completing the above, an activation email will be sent
Here you are able to download all your communication, including
to you.
your claims statements, tax certificates and SMSs.
Preventative
• Click on ‘Activate’ in the email to activate your account.
care
Benefits
Should you experience any problems regarding the registration Here you are able to view your available and used benefits for
process, please contact the website contact centre on the year.
Managed
0860 002 134 for assistance.
care
Claims
To reset your Member Zone password, follow these easy
You have the following options when searching for claims:
steps:
Emergencies
• Enter date: Select the year and month you want to search
• Visit www.sasolmed.co.za.
for.
• Select ‘LOGIN’ and ‘Can’t access your account’.
• Select the claims type: View claims by status ‘In progress/
• Enter your username or email address and click on ‘Validate’. Paid’.
PMBs
• Select the dependant: Select which dependant you want to
see claims for.
FAQ
Terms
Welcome
• Click on the doctor’s card: Click on the provider whose claims PLEASE NOTE that this functionality only provides you with
Contact
you would like to search for. a reference number and does not constitute an authorisation
for treatment or services. Please be on the lookout for
Contributions feedback on your authorisation request and contact us on
Membership
Here you can view your contribution for the current year, per 0860 002 134 if you do not receive feedback within two to
month. three business days of submitting your request.
Provider Search Documents Library

Here you will find all providers, including general practitioners
Claiming
that have contracted with Sasolmed. Here you will find the member guide, contribution tables, rules
and annexures approved by the Council for Medical Schemes and
My Family that the Scheme adheres to, forms and any other information
Selecting
a PGP
Here you can view and update your dependant’s personal details, that the Scheme would like to share with you.
contact information and street and postal addresses, as well as
your next of kin details. Inbox
Preventative
Here you can view the history of your queries, emails, SMSs,
Balances
care
scanned documents and other correspondence submitted to
Here you can view your contribution, member portion and
the Scheme.
HealthSaver (if applicable) balances for the current year.
Managed
care
My Authorisations
On this screen you can:
Emergencies
• request a new chronic medicine authorisation;
• update an existing chronic medicine authorisation;
• view currently authorised chronic medicine; and
• request hospital pre-authorisation.
PMBs
FAQ
Terms
Welcome
ELECTRONIC HEALTH RECORD (EHR)
The EHR is an app that you can use on your desktop and on your smartphone. You can use it to find information on your medical
Contact
condition, surgical procedures and medication.
You can also use it to:
Membership
• View your medical history, including immunisations and allergies.
• Track your health measurements, such as height, weight, BMI, blood pressure results and blood sugar levels.
• View claims.
Claiming
• View your medication.
• View hospital visits.
• See how healthy you are by taking the health risk assessment.
Selecting
a PGP
HOW TO REGISTER VIA YOUR COMPUTER
Preventative
care
STEP 1: Click here to register or login to the Sasolmed Member Zone.
STEP 2: Click on the Electronic Health Record tab.
Managed
Note: If you don’t see the Electronic Health Record tab, call 0860 002 134 to activate
care
your Electronic Health Record.
Emergencies
Once you are logged in:
• Click on Your Profile and ensure your details are correct.
PMBs
• Go to Your Health and capture your health measurements.
FAQ
Terms
3
IN THIS CHAPTER
• Who is eligible for membership?
• Who can be registered

as dependants?
• Who is not eligible for

membership?
• How do I apply for membership

or change my membership
details?
• How are my membership

contributions calculated?
• What should I do with my

membership card?
MEMBERSHIP • What waiting periods will

apply to new members or
dependants?
Welcome
WHO IS ELIGIBLE FOR MEMBERSHIP?
Contact
REMEMBER: Application for registration of newborns
Membership of a registered medical scheme is compulsory for all
must be made within 30 days of birth to ensure no
Sasol employees, either as principal members of Sasolmed or as
waiting periods are applied.
a registered dependant of a spouse or partner’s medical scheme.
Membership
Employees retiring from Sasol’s service or who are declared
medically disabled are also eligible for membership.
WHO CAN BE REGISTERED AS DEPENDANTS?
Claiming
• Immediate family member(s): A parent or child of a principal
member for whom the member is liable for family care and
support
Selecting
a PGP
• A member’s spouse
• A member’s partner(s): A person with whom the member has a
Preventative
committed relationship akin to marriage of two years or more,
care
based on objective criteria of mutual dependency and a shared
and common household, irrespective of the gender of either
party
Managed
• Surviving spouse members (widow/widower): Entitled to
care
continuation of membership of Sasolmed, provided that they
were registered as dependants at the time of the member’s death
Emergencies
• Foster children
• Adopted children
• Children where the principal member has a parenting plan or
shared responsibility according to a court
PMBs
• Grandchildren and stepchildren, if specific criteria are met.
FAQ
Terms
Welcome
WHO IS NOT ELIGIBLE FOR MEMBERSHIP? HOW ARE MY MEMBERSHIP CONTRIBUTIONS
• An employee who is registered as a dependant of his/her CALCULATED?
Contact
spouse’s medical scheme may not be admitted to Sasolmed, The monthly contributions are determined by the following:
as the Medical Schemes Act does not permit membership of
more than one medical scheme at a time; • monthly income with a minimum and a maximum salary
Membership
cut-off amount revised annually on 1 October;
• Ex-spouses;
• family size;
• A surviving spouse (widow/widower) who:
• active working employees: subsidised (MSP) or non-subsidised
– remarries and upon remarriage is registered as a
salary personnel (SP); and
Claiming
dependant on the new spouse’s medical scheme (if other
than Sasolmed); or • pensioners: subsidised (Pension Fund A and B Scheme) or
non-subsidised (Pension Fund C Scheme) or Provident Fund.
– terminates membership in writing; he/she will not be
Selecting
a PGP
allowed to rejoin at a later stage or register any new MSPs (Monthly Salary Personnel): 40% of the total
dependants; contributions will be deducted from the employee’s salary
• A pensioner who terminates membership. He/she will not be and 60% of the remaining contribution is subsidised by the
Preventative
allowed to rejoin at a later stage. company.
care
A copy of the full membership eligibility document is available SPs (Salary Personnel): 100% of the contribution will be
on request. deducted from the employee’s salary, as the subsidy is
Managed
included in the TGP (Total Guaranteed Package).
care
HOW DO I APPLY FOR MEMBERSHIP OR CHANGE MY
MEMBERSHIP DETAILS? Pension Fund A and B Scheme: 40% of the total contributions
Emergencies
All membership application forms or any changes to membership will be deducted from the monthly pension and 60% of the
details, must be submitted directly to your HR department or remaining contribution is subsidised by the Pension Fund.
Pension Fund Office and not to Momentum Health Solutions,
Pension Fund C Scheme: 100% of the contribution will be
except for direct-paying members of Sasolmed.
PMBs
deducted from the monthly pension by debit order.
Provident Fund: 100% of the contribution will be deducted via
FAQ
debit order.
Terms
Welcome
WHAT SHOULD I DO WITH MY MEMBERSHIP CARD? Please look after your membership card. Do not provide
it to anyone other than your registered dependants.
Contact
Your membership card is proof of membership of Sasolmed and
reflects the following information: Fraudulent use of membership cards will lead to
suspension or termination of your membership.
• your membership number;
Membership
• your initials, surname and ID number; IMPORTANT
• the names of your registered dependants and their birth Please inform Sasolmed immediately of any changes
dates; and in your personal details (for example address, contact
Claiming
• the dates from which you are entitled to benefits. numbers, marital status and number of dependants) by
completing a Member Record Amendment form, available
In line with the latest trends in the healthcare industry, Sasolmed from your HR department or the Sasol Pension Fund.
Selecting
has rolled out an electronic membership card, which is available
a PGP
Membership will terminate when you leave the service of
via the Sasolmed (NEW) app. You can download it from the app
your employer. Please return your membership card to your
store on your smartphone.
employer or the Sasol Pension Fund if your membership
Preventative
comes to an end.
care
WHAT WAITING PERIODS WILL APPLY TO NEW
Managed
MEMBERS OR DEPENDANTS?
care
Sasolmed reserves the right to impose waiting periods.
Emergencies
When waiting periods will apply
A three-month general waiting period will apply to:
• all dependants who have not had cover for more than 90 days
and whose period of membership of his/her previous medical
PMBs
scheme is less than 24 months
• newborns not registered within 30 days of birth.
FAQ
Terms
Welcome
Late joiner penalties will apply:
• to members or adult dependants who join over the age of 35 and
Contact
who were not previously members of a medical scheme or who had
a break in coverage of more than three consecutive months since
1 April 2001.
Membership
A 12-month medical condition-specific waiting period will apply:
• to all dependants who have not had cover for more than 90 days
and whose period of membership of his/her previous medical
Claiming
scheme is less than 24 months.
A three-month general waiting period and 12-month condition-
Selecting
specific waiting period will apply:
a PGP
• for the dependant of an existing member who joins after the
member and whose gap in medical cover exceeds 90 days.
Preventative
When waiting periods will not apply
care
• No waiting period will apply to registered child dependants born
during the period of membership and registered from date of birth.
Managed
• No waiting period will apply to registered spouses who are
care
registered on the Scheme from the date of marriage.
• No three or 12-month waiting period will apply if you are forced to
Emergencies
transfer membership because of change of employment.
• If your dependant changes medical schemes and this changeover is
made within a 90-day period, no three or 12-month waiting period
will apply. Any outstanding portion of a waiting period imposed
PMBs
by a former medical scheme will apply and prescribed minimum
benefits will not be available to you or your dependants during
FAQ
such periods.
Terms
4
IN THIS CHAPTER
• How should I submit
my accounts?
• How can I help speed up my

claims processing?
• When can I expect payment?
CLAIMING
• Should I pay the healthcare
provider directly?
MADE EASY
• How will I know what was paid?
• How do I submit an ex gratia

claim?
Welcome
HOW SHOULD I SUBMIT MY ACCOUNTS? of ICD-10 codes under Frequently Asked Questions); and
• Your healthcare provider will give you an invoice. If you have – the healthcare provider’s practice number.
Contact
paid the service provider upfront, you will also be given a
receipt. HOW CAN I HELP SPEED UP MY CLAIMS
PROCESSING?
Membership
• Submit your invoices and receipts to Sasolmed as soon as
possible. You can post it, scan and email the claim. Only Check that prescriptions for medicine show all your details.
claims received within four months of treatment will be paid. Also check that the correct quantity of medication dispensed
Therefore: is reflected on the claim. If the pharmacy omits any of these
details, the Scheme will not be able to process your claim, and
Claiming
– send the first account you receive;
this may lead to delays.
– do not send statements;
– if you have already paid the account and have attached the Dental treatment often requires additional work by a dental
Selecting
a PGP
receipt, clearly mark the account ‘paid by member’; and technician. He/she bills the dentist, who adds this to your
– do not submit accounts marked ‘for your information only’ account and attaches a copy of the technician’s account.
or accounts showing only a balance brought forward; such Please submit both accounts and ensure that your name and
Preventative
accounts are for your records and should be used to check membership number are reflected on each account.
care
against payments reflected on your statements.
Incorrect or incomplete ICD-10 codes will result in a claim being
• The Medical Schemes Act requires that healthcare providers rejected for payment. Check to make sure that the full ICD-10
give full details on all accounts. Before submitting claims,
Managed
code is on the claim. If necessary, check with the healthcare
care
please check that your account shows: provider before leaving the practice.
– your name and initials;
WHEN CAN I EXPECT PAYMENT?
Emergencies
– your membership number;
– the treatment date; The Scheme has a regular payment cycle, with two payment
– names of patients, as indicated on your membership card runs per month to members and healthcare providers. The
(not nicknames); payment runs will generally happen in the second and last
PMBs
– the amount charged; week of that particular month. Remember that some months
– tariff and ICD-10 codes, where applicable (see explanation have five weeks. All valid claims received by the Scheme will be
processed on this basis.
FAQ
Terms
Welcome
After the Scheme receives your claim, we will process it and As your email address and cell phone number are loaded on our
Contact
either refund you or pay your healthcare provider by direct records, you will receive confirmation of every claim that has
transfer to a bank account, depending on the payment method been paid or rejected.
that has been chosen.
You will receive:
Membership
SHOULD I PAY THE HEALTHCARE PROVIDER
• an email to acknowledge that the claim has been processed;
DIRECTLY?
and
You can submit the account to the Scheme, who will refund
• an SMS indicating the amount that will be credited to you or
Claiming
you up to the Sasolmed tariff limit, deducting co-payments
the service provider in the next payment run.
where applicable. Any refunds will be offset against member
portions owing to Sasolmed, if applicable. Please check regularly to ensure that all your personal details,
Selecting
a PGP
including your bank account details, are correct for the
electronic payment of refunds.
PLEASE NOTE: Most healthcare providers submit claims
Important messages will also be shared with you on your
Preventative
directly to the Scheme, who then reimburses the provider.
monthly statement.
care
This is also reflected on your monthly statement.
In the event that your healthcare provider does not HOW DO I SUBMIT AN EX GRATIA CLAIM?
submit claims directly to the Scheme and requires you
Managed
to pay the account in full, the claim, with the proof Members who have special requests that fall outside the
care
of payment, must be sent to claims@sasolmed.co.za benefits provided in terms of the rules of the Scheme, have
within four months of date of service. exceeded their benefits or who require assistance as a result
Emergencies
of financial hardship, may request the Ex Gratia Committee to
consider additional assistance.
HOW WILL I KNOW WHAT WAS PAID?
A statement will be posted or emailed to you. This statement Each case is carefully evaluated in terms of its merits, taking
is compiled each month-end. Members will receive a single into consideration factors such as:
PMBs
statement with full payment details.
• whether the request is specifically excluded in the Scheme
rules;
FAQ
Terms
Welcome
• generally accepted clinically appropriate protocols;
Contact
• motivations and clinical reports submitted by doctors/specialists;
• requirements to perform duties in employ;
Membership
• prognosis; and
• whether the request is fair to the rest of the beneficiaries of the
Scheme.
Claiming
A panel consisting of at least one experienced Medical Advisor and
members of the Board of Trustees make a decision based on the
above, but with the understanding that the rationale used to reach
the decisions is confidential and cannot be disclosed to anyone
Selecting
a PGP
outside the Committee.
The Committee considers clinical outcomes when making a funding
Preventative
decision, but does not take responsibility for the clinical outcomes.
care
Visit www.sasolmed.co.za for the ex gratia application form or
send an email to exgratia@sasolmed.co.za.
Managed
care
Emergencies
PMBs
FAQ
Terms
5
IN THIS CHAPTER
• Why do I need to choose a PGP?
• How do I select a PGP?
• What if my specific PGP is

not available?
• What if different members of

my family prefer different PGPs?
• What if we are on holiday and

cannot visit our PGP?
• What if we have an emergency?
• What if I voluntarily consult

a non-PGP?
SELECTING A • Can I change my mind about

a PGP?
PREFERRED GENERAL • Who can register an additional

PGP and how?
PRACTITIONER (PGP) • What if I need to see a

specialist?
Welcome
WHY DO I NEED TO CHOOSE A PGP? HOW DO I SELECT A PGP?
The key to good healthcare is the development of a strong Please read more about your option selection and nominating
Contact
relationship with a general practitioner (GP) that you trust and a PGP on pages 2, 7 and 8 of the 2021 Benefit and Contribution
respect. A family doctor who knows your medical history and Schedule (available on www.sasolmed.co.za or via the Sasol
background is important to ensure appropriate hospitalisation, Intranet).
Membership
medical testing and specialist interventions that you may
require. A GP is generally best placed to see the ’big picture’ If you choose the Comprehensive Network Option, you may
when it comes to your health and that of your loved ones. nominate any GP of your choice, as your PGP.
If you choose the Restricted Network Option (and particularly
Claiming
It is therefore especially important that one such GP becomes
if you have a chronic condition), you may also nominate
the co-ordinator of your care, so that a record of your and your
any PGP, but we strongly encourage you to nominate a PGP
loved ones’ medical history can be kept in one place and shared
from the Restricted Network GP list, which you will find on
Selecting
with specialists and other providers when necessary.
a PGP
www.sasolmed.co.za or via the Sasol Intranet.
Visiting more than one GP on a regular basis holds major
The usual co-payment for a consultation with a PGP will be
disadvantages for both members and Sasolmed, such as:
Preventative
waived for the first two visits (per beneficiary) if the PGP is
care
• conflicting diagnoses and treatment; an in-network PGP. Use the ‘Locator’ in the Member Zone or
contact Sasolmed’s Customer Services on 0860 002 134 to
• additional costs being incurred where similar diagnostic tests
verify whether your PGP is on the network.
are repeated or medicines are duplicated by different GPs; and
Managed
care
• an increased opportunity for fraud through members Members should complete a PGP selection form at their HR
potentially allowing their Sasolmed membership cards to be department or contact Sasolmed’s Customer Services on
used by other persons not known to the different GPs being 0860 002 134 to register the PGP.
Emergencies
visited.
WHAT IF MY SPECIFIC PGP IS NOT AVAILABLE?
For this reason the Scheme has introduced the concept of
If the PGP is part of a group practice of general practitioners,
Preferred General Practitioner (PGP) selection to encourage
PMBs
members may visit any doctor who is part of the group practice,
you to consistently use a GP of your choice, rather than move
provided the account/claim is submitted under the group
between GPs on a regular basis.
practice number.
FAQ
Terms
Welcome
When the PGP is not available, the doctor standing in (known as WHAT IF I VOLUNTARILY CONSULT A NON-PGP?
Contact
the locum) will automatically be considered as the PGP. Please read more in the detailed 2021 Benefit and Contribution
Schedule available at www.sasolmed.co.za and on the Sasol
When the PGP is not available and does not have an appointed
Intranet.
Membership
locum, but has chosen a secondary GP to treat Sasolmed
patients, the receptionist must advise you of the secondary GP.
CAN I CHANGE MY MIND ABOUT A PGP?
WHAT IF DIFFERENT MEMBERS OF MY FAMILY The principal member and his/her dependants may change their
PREFER DIFFERENT PGPs? PGP selection once every six months. To update a PGP, simply
Claiming
contact Sasolmed Customer Services on 0860 002 134 or email
It is possible for each member of the family to have a different
enquiries@sasolmed.co.za. Please ensure that you provide
PGP. Each adult dependant and each child dependant over the
Sasolmed with your valid membership number and the seven-
Selecting
age of 16 (if he/she has the consent of the principal member
a PGP
digit practice number of the chosen PGP. If different family
to do so) may choose his/her own PGP. For child dependants
members have selected different PGPs, the seven-digit practice
under the age of 16 years, the parent registered as the principal
number of the PGP must be given for each beneficiary.
Preventative
member must select the PGP.
care
WHAT IF WE ARE ON HOLIDAY AND CANNOT VISIT WHO CAN REGISTER AN ADDITIONAL PGP AND
OUR PGP? HOW?
Managed
When a Sasolmed member is on holiday and needs to visit a Qualifying beneficiaries Proof to submit with application
care
doctor, such visits would be covered by the ‘out of town’ benefit
Members residing and The member must submit proof
of three visits per family to a doctor other than the selected
working in different of residence and workplace when
Emergencies
PGP. towns working away from home by
means of an affidavit or written
WHAT IF WE HAVE AN EMERGENCY? confirmation from the employer.
In the event of emergencies, the PGP rules will not necessarily Children studying/in The member must submit a letter
PMBs
apply. However, Sasolmed needs to be informed of the boarding schools from the school for children in
circumstances within three working days to ensure that claims boarding school.
arising from the event are allocated to the appropriate benefit.
FAQ
Terms
Welcome
Qualifying beneficiaries Proof to submit with application
Contact
Children of divorced The member must submit the
parents practice name and number for a
Membership
PGP at the place of residence of
both parents.
Migrant workers (living Migrant workers must submit an

in hostels) with family affidavit or proof of temporary
Claiming
living in a different (hostel) and permanent residence
town (spouse and children).
Members travelling The member involved in special
Selecting
for work or involved in projects away from home must
a PGP
special projects away submit confirmation from the
from home employer of the duration of
the project.
Preventative
care
WHAT IF I NEED TO SEE A SPECIALIST?
To ensure co-ordinated care, you should be referred to any
Managed
specialists by your PGP. To create a specialist referral, your PGP
care
needs to call 0860 002 134 before you visit a specialist, to
obtain a specialist referral number.
Emergencies
The referral number will apply to either a type of specialist (for
example, a dermatologist) or a specific specialist for a period of
time that your PGP decides on, which can be up to six months.
The patient still has the choice of which specialist to visit.
PMBs
FAQ
Terms
Welcome
There are some exceptions to this rule and you will not need a specialist
referral number in the following instances:
Contact
• one visit per year to a gynaecologist for a gynaecological check-up
and pap smear for female patients;
Membership
• one visit per year to a urologist for a check-up for male patients;
• visits to a paediatrician for children under one year of age;
• visits to optical and dental specialists; and
Claiming
• maternity consultations by a gynaecologist.
In case of an emergency, where a patient had to consult a specialist
Selecting
a PGP
without prior authorisation, a referral number can be obtained after
the visit. The patient would need to contact his/her PGP to obtain the
referral number within 72 hours of the emergency.
Preventative
care
The Scheme also realises that there might be unique cases
where a member has to see a specialist on a more regular basis
due to a specific condition. Members can apply to the Ex Gratia
Managed
Committee for exemption from the Specialist Co-ordination of
care
Care Programme. The Committee will consider this request on
medical and clinical evidence, assisted by the Medical Advisor.
Emergencies
Members should remember that obtaining a referral number from a
PGP is not a guarantee of payment – specialist consultations will be
paid up to the Scheme tariff.
PMBs
FAQ
Terms
6
IN THIS CHAPTER
• What do the preventative
PREVENTATIVE
care benefits include?
• Why should I go for
CARE
screening tests?
• How can Sasolmed help me

to stop smoking?
Welcome
WHAT DO THE PREVENTATIVE
CARE BENEFITS INCLUDE? BLOOD GLUCOSE (FASTING) MIDSTREAM URINE
Contact
Sasolmed covers you and your family Age: All ages
DIPSTICK TEST
for a variety of annual screening Gender: Male and female Age: All ages
Membership
tests and vaccinations to help you Gender: Male and female
monitor and manage your health. BONE DENSITY SCAN
Using these benefits will not affect OCCULT BLOOD (FAECAL)
your normal benefits. The age and Age: 65+
Gender: Male and female Age: 50+
Claiming
gender limits have been determined
by clinical input. As these benefits Gender: Male and female
are updated and enhanced on a CHOLESTEROL
PAP SMEAR
Selecting
regular basis, they are not listed Age: 20+
a PGP
here. Please refer to your Benefit Gender: Male and female Age: 25+
and Contribution Schedule for full Gender: Female
information on all preventative care
Preventative
FLU VACCINATION
benefits.
care
Age: Six months+
PNEUMOCOCCAL
Notes: VACCINATION
Gender: Male and female
1. This will include a lipogram. Age: 18+
Managed
care
2. Recommended for high-risk Gender: Male and female
HIV TEST
patients: The elderly, smokers,
diabetics and patients with cancer, Age: All ages
PSA (PROSTATE-SPECIFIC
Emergencies
recurrent lung disease, asthma, Gender: Male and female
bronchitis, liver, kidney and heart ANTIGEN)
failure and wasting and debilitating
MAMMOGRAMS Age: 45+
illnesses every five years.
Gender: Male
3. Bone density scan every two years. Age: 50+
PMBs
4. Mammogram every three years. Gender: Female
The age and gender limits will be
FAQ
determined by clinical input.
Terms
Welcome
WHY SHOULD I GO FOR SCREENING TESTS?
Contact
Having screening tests done is one of the most important
things you can do for your health. Screenings are medical tests
that check for diseases before there are any known symptoms.
Membership
Screenings can help doctors find diseases early, when the
diseases may be easier to treat. Do bear in mind, though,
that screening tests are only indicative. For a more accurate
diagnosis of a chronic condition, your doctor may refer you for
Claiming
more extensive blood tests to determine whether you require
chronic medication.
Selecting
a PGP
HOW CAN SASOLMED HELP ME TO STOP SMOKING?
Sasolmed has engaged Allen Carr’s Easyway to Stop Smoking
programme to provide Sasolmed beneficiaries with a stop
Preventative
smoking programme. This is part of the ongoing focus on Sasolmed chose to partner with Allen Carr, based on their
care
providing comprehensive preventative care benefits to all unrivalled, independent, scientifically published success
beneficiaries. rates, making them the most successful smoking cessation
programme in the world. After examination of their success
Managed
The internationally renowned programme is a drug-free
care
rates, Allen Carr has been endorsed by the Cancer Association
programme that examines and addresses the reasons why of South Africa (CANSA).
people smoke. Once the real problem is recognised, namely
Emergencies
mental addiction, withdrawal becomes easy to manage and There are 150 Easyway Clinics in over 50 countries worldwide
no willpower is required. Most smokers require one five- and in South Africa they have branches in Cape Town, Durban,
hour session with smoke breaks throughout. They also offer East London, Johannesburg, Port Elizabeth, Secunda and in
two optional, free back-up sessions for those smokers who major centres countrywide for groups of 20 or more people.
PMBs
find it difficult to quit. Allen Carr’s Easyway to Stop Smoking
Programme provides a money-back guarantee for smokers who To book to attend one of the Easyway Clinics, please phone the
attended all three sessions and continue to smoke. Allen Carr National booking line on 0861 100 200.
FAQ
Terms
IN THIS CHAPTER
7 • What is managed care?
• Chronic Medicine Management

Programme
• Hospital Benefit and pre-

authorisation management
• Dental management
• Optometry management
• Back and neck rehabilitation

Programme (Documentation
Based Care [DBC])
• Oncology Management
Programme
• Weight Management
Programme
• YourLife Programme (HIV/AIDS)
MANAGED
• Mental Health Programme
• Active Disease Risk
CARE
Management Programme
• Maternity Management
Programme
• Paed-IQ BabyLine
Welcome
WHAT IS MANAGED CARE?
Contact
Managed care is a holistic approach that aims to:
• promote health and prevent disease; and
Membership
• treat existing conditions appropriately and cost-
effectively, whilst ensuring high-quality care.
Sasolmed uses a dedicated managed care company,
Claiming
Momentum Health Solutions, to provide managed
healthcare services to its members.
Selecting
Within Momentum Health Solutions there is a
a PGP
specialised unit, called the Clinical Policy Unit,
which collates the clinical policies that underpin all
managed care programmes. Such policies are based
Preventative
on the scientific evidence of medical practices,
care
economic considerations that include efficiencies
of healthcare interventions and their budgetary
impact, as well as the relevant legal framework. The
Managed
care
Clinical Policy Unit further supports all managed
care programmes and the Scheme on day-to-day
issues that require clinical expertise. This ensures
Emergencies
that all special payment requests and appeals by
beneficiaries are duly considered.
This chapter explains how various benefits are
PMBs
managed and also outlines the managed care
programmes offered by Sasolmed.
FAQ
Terms
Welcome
CHRONIC MEDICINE MANAGEMENT BACK AND NECK REHABILITATION
Contact
PROGRAMME PROGRAMME (DOCUMENTATION BASED
The chronic medication management process ensures
CARE [DBC])
Membership
access to cost-effective and appropriate treatment and This is a programme intervention for members suffering
management through a formal drug utilisation review. from back and neck problems. It works on the concept
Tel: 0860 002 134 | Email: chronic@sasolmed.co.za of active muscle reconditioning, supported by scientific
clinical studies.
Claiming
Tel: 0860 002 134 | Email: adrm@sasolmed.co.za
HOSPITAL BENEFIT AND
PRE-AUTHORISATION MANAGEMENT
ONCOLOGY MANAGEMENT
Selecting
Assists members in obtaining authorisation before being
PROGRAMME
a PGP
admitted to hospital or undergoing any other examinations
specified by the Scheme for pre-authorisation. This programme supports members in their time of need.
If you are diagnosed with cancer, you are encouraged to
Preventative
Tel: 0860 002 134
register on the programme as soon as possible.
care
Tel: 0860 002 134 | Email: oncology@sasolmed.co.za
DENTAL MANAGEMENT
Managed
WEIGHT MANAGEMENT PROGRAMME
care
This dental benefit ensures cost-effective, quality dentistry
for those who care for their teeth and general health. The programme assists with weight loss through a
Emergencies
Tel: 0860 002 134 | Email: dental@sasolmed.co.za comprehensive assessment and exercise prescription by
a BASA (Biokineticist Association of South Africa)
biokineticist.
OPTOMETRY MANAGEMENT
Tel: 0860 002 134
PMBs
Optometry Management provides you with clinically Email: weightmanagement@sasolmed.co.za
essential optometric benefits that are financially validated.
Tel: 0860 002 134 | Email: enquiries@sasolmed.co.za
FAQ
Terms
Welcome
YOURLIFE PROGRAMME (HIV/AIDS) MATERNITY MANAGEMENT
Contact
PROGRAMME
The YourLife Programme offers payment of the
necessary HIV medication and pathology claims, as well This programme offers support to all moms-to-be
Membership
as clinical and emotional support and advice on how to throughout their pregnancy journey, as well as during
manage your condition. their confinement in hospital.
Tel: 0860 100 646 | Email: yourlife@sasolmed.co.za Tel: 0860 002 134
Email: maternity@sasolmed.co.za
Claiming
MENTAL HEALTH PROGRAMME
This programme has been built on the principle of PAED-IQ BABYLINE
Selecting
a PGP
providing the best quality primary mental healthcare
Paed-IQ BabyLine is the first dedicated 24-hour
that is available.
parent advice line in South Africa and it offers clinical
Tel: 0860 002 134
childcare assessment and telephonic guidance.
Preventative
Email: mentalhealth@sasolmed.co.za
care
Tel: 0860 666 112
ACTIVE DISEASE RISK MANAGEMENT

ALLEN CARR EASYWAY SMOKING
Managed
CESSATION PROGRAMME
care
This programme identifies members who are at risk of
suffering complications or advancement of their chronic The Allen Carr Easyway Smoking Cessation Programme
conditions. It helps these members control, manage and boasts a 90% success rate world-wide. Now Sasolmed
Emergencies
monitor their conditions. members can complete the programme totally free of
Tel: 0860 002 134 | Email: adrm@sasolmed.co.za charge.
Tel: 0861 100 200 (call the booking line directly to book
PMBs
attendance in your area)
www.allencarr.co.za
FAQ
Terms
Welcome
MEDICINE MANAGEMENT PROGRAMME You may, however, have to select a generic product over more
expensive, brand-name product. Should you prefer the more
Contact
Medication forms an important part of healthcare costs and, expensive product, Sasolmed will only pay up to the MRP and you
as such, necessitates careful management by Sasolmed. For will have to pay the difference in price to the dispenser.
Membership
members to continue enjoying reasonable contribution
Given that generic medication within a specific MRP group are
increases without compromising quality of care, Sasolmed
either identical to one another (except for their appearance or
applies generic reference pricing, otherwise known as the
their packaging) or otherwise very similar (for example, only
Medicine Reference Price (MRP) to acute and chronic medication.
the inactive ingredients of products differ slightly), a given
Claiming
What is the MRP list? condition can be treated with any one medication within such
a group. Therefore, to avoid unnecessary co-payments, ask
The MRP list is a reference pricing system that uses a standard,
your doctor and pharmacist to prescribe and dispense generic
Selecting
industry-wide reference pricing system for generically similar
a PGP
medication that is fully covered within the MRP list.
products. The fundamental principle of any reference pricing
system is that it does not restrict a member’s choice of Co-payments are applied in accordance with the Scheme rules.
medication, but instead, limits the amount that will be paid
Preventative
for the medication. The MRP ensures the availability of For more information on the MRP, please refer to the Chronic
care
medication without co-payments (outside of the Scheme rules) Medicine Management Programme leaflet at
being necessary. In other words, you will be able to afford the www.sasolmed.co.za.
medication you need without paying for it from your own pocket.
Managed
What co-payments may apply to my chronic medication?
care
From 1 January 2021, the Sasolmed Reference Price List will
be known as the MRP List. All medication claims (chronic and
Emergencies
acute) are paid against the medication price in the MRP List*.
This means that there might be an increase or decrease in your
co-payment, depending on the medicine price as per the MRP
list, from time to time. You can limit or avoid additional
PMBs
co-payments by asking your pharmacist to offer you the
most cost-effective generic alternatives when collecting your
FAQ
medicine.
Terms
Welcome
Network formularies (list of prescribed medication) What you need to do to limit or avoid co-payments on
Contact
your chronic medication
From January 2021, Sasolmed members will have the option to
choose between two benefit options: 1. Ask your doctor to prescribe medicine that is part of the
Membership
applicable network formulary for the option you have selected.
• On the Comprehensive Network Option, members can Read more about this in the 2021 Benefit and Contribution
consult a wide network of general practitioners (GPs) and Schedule or visit www.mediscor.co.za and choose the
pharmacies as their designated service providers (DSPs) for applicable formulary for the Sasolmed Option you have
their chronic conditions. On this option, you can use ANY
Claiming
selected.
GP and ANY PHARMACY for your and your family’s chronic
2. Use Medipost courier pharmacy to order your chronic medicine
consultation and medication needs.
delivery, especially if you have chosen the Restricted Network
Selecting
Option.
a PGP
A comprehensive medication formulary will apply in respect
of chronic medication. The Comprehensive network formulary 3. Discuss any change in your medication with your pharmacist
covers a more extensive list of medication than the Restricted or doctor and consider whether you would prefer to use:
Preventative
network formulary that applies to the Restricted Network – your current medication, given that you will have to cover
care
Option. the difference between the cost of your medicine and the
• On the Restricted Network Option, members agree to consult MRP; or
only a RESTRICTED network of GPs and only use Medipost – one of the generic alternatives on the MRP List that are
Managed
Courier Pharmacy for their chronic medication needs.
care
covered in full on the MRP List**.
Members agree to use medication on the Restricted network 4. You do not have to call the Medicine Management Programme
Emergencies
formulary for their chronic medication needs. to change your medication to a generic alternative. The
Members may be liable for additional co-payments on pharmacy will be able to claim the equivalent you require.
claims if they use non-network GPs, if a pharmacy other
If you make use of a courier pharmacy and decide to change
than the Medipost Courier Pharmacy is used, or if they use
to a generic alternative, inform your courier pharmacy of
PMBs
medication that is not on the Restricted network formulary.
the change so that they can send you the relevant alternative
in future.
WHAT YOU NEED TO DO TO AVOID A CO-PAYMENT OR AN
FAQ
INCREASE IN YOUR CURRENT CO-PAYMENT
Terms
Welcome
2. Click on ‘Formularies’.
* Medicine Reference Price (MRP) List
3. Choose your option – either Comprehensive or Restricted.
Contact
The MRP List (previously known as Sasolmed Reference
4. Choose either the diagnosis or the medication and click
Price List) is a reference pricing system that is used
‘Search’.
in conjunction with formularies and pre-authorisation to
Membership
manage medication costs. The system uses an industry- 5. Check the strength of your medication to make sure you find
wide standard for generically similar products to limit the relevant alternative.
the amount that will be paid in medication prices. It does 6. The alternative is linked to your existing authorisation, so unless
not restrict the choice of medication, but aims to control you change to an item or quantity that is outside your chronic
Claiming
the cost of medication by encouraging members to make medication basket, you can claim the alternative without needing
use of generic products, so they derive maximum value to update your chronic medication authorisation.
from their chronic medication benefit limits.
What medication will not be covered from my acute/
Selecting
a PGP
chronic medication benefit?
** MRP co-payment The Medicine Exclusion List (MEL) is a list of medication that
Preventative
The MRP co-payment is the difference between the are excluded for payment from the acute/chronic medication
benefit for various reasons. These include:
care
cost of your medication and the reference price. Such a
co-payment will be payable if you claim for chronic
• medication not proven to have relevant clinical value;
medication that is not on the MRP List, instead of choosing
• medication that is more expensive compared to equally
Managed
an alternative from the list; for example, an appropriate
care
generic equivalent. effective and safe alternatives;
• medication prone to abuse; quantity limits are set for
Emergencies
How to find alternative medication that is covered on the sedatives and analgesics to reduce abuse;
MRP List • newly registered products under review; and
A full list of alternative medication can be found in the Sasolmed • medication that is not covered as per Sasolmed Scheme
Member Zone. rules.
PMBs
1. Vist www.mediscor.co.za or visit www.sasolmed.co.za and
login with your Member Zone username and password.
FAQ
Terms
Welcome
The Chronic Medicine Management Programme Each application for authorisation of medicine from the
Contact
chronic medicine benefit is subject to the application of the
What is chronic medication risk management? Programme’s clinical guidelines and protocols. Authorisation
Chronic medicines are indicated for prolonged conditions that and payment of medicine from the chronic medicine benefit is
are often life-long. To ensure that the most appropriate and
Membership
also subject to Scheme rules, waiting periods, exclusions and
cost-effective treatment is prescribed, payment of medication available benefits, as amended from time to time.
of such conditions must be approved by the Scheme.
How can I benefit from the Chronic Medicine
The Chronic Medicine Management Programme authorises Management Programme?
Claiming
payment of appropriate, high-quality and cost-effective
To ensure you get the most appropriate, high-quality and
medicine from the chronic medicines benefit. Conditions
cost-effective treatment for your chronic condition, you need
for which such medicine is authorised are determined by the
Selecting
to apply and be authorised for chronic medicine through the
a PGP
Scheme in conjunction with medical scheme legislation.
Programme, subject to the guidelines and protocols. The
Medication for illnesses listed on the prescribed minimum
prescribed medicine that will be authorised is determined by
benefits chronic disease list (CDL) has to be covered by the
Sasolmed and medical scheme legislation and is subject to
Preventative
Scheme in terms of legislation.
Scheme rules, waiting periods and exclusions. Medication is
care
paid from your available chronic medication benefit.
When you apply for chronic medicine benefits, you are approved
Managed
care
for treatment of your chronic condition and will have access to
a list of pre-approved medicines, referred to as a basket. This
means that when you need to change or add a new medicine
Emergencies
for your condition, you can do this quickly and easily at your
pharmacy with your new prescription.
It is important to note that not all conditions are managed
PMBs
this way and you may need to still call the Chronic Medicine
Management Programme if you use a medication that is not
in your condition’s basket or if you are diagnosed with a new
FAQ
Terms
Welcome
condition. The quantity of each prescription in the basket is • test results, e.g. lipogram results, HbA1c and lung-function
limited to the most commonly prescribed monthly dose. If you tests; and
Contact
require higher quantities than those in the basket, you may • a motivation provided by your prescribing doctor.
contact us for an extension of the authorisation.
Applying telephonically
Membership
Pre-approved medicine in the basket will still be subject to the • Your pharmacist or prescribing doctor may call 0860 002 134
MRP and formulary co-payments. between 08:00 and 17:00.
You can check for co-payments with your pharmacist or view • We will guide the doctor or pharmacist through the process.
Claiming
the baskets, formularies and MRP List at www.mediscor.co.za. • The doctor and pharmacist will be informed of any
co-payments.
How to apply telephonically or online
Selecting
If you need to register for, or update, your chronic medicine Email
a PGP
authorisation, your doctor or pharmacist can do this • Email the prescription, with all the relevant information, as
telephonically or online. indicated above to chronic@sasolmed.co.za.
Preventative
• A reference number will be provided for follow-up on the
We will need the following information:
care
progress of the application.
• the date of birth of the person applying; Online
• the date of birth of the person applying;
• Visit www.sasolmed.co.za.
Managed
• the ICD-10 diagnosis code; and
• the ICD-10 diagnosis code; and
care
•
• the
the healthcare
healthcare provider’s
provider’s practice
practice number.
number. • Click on ‘Login’.
• Enter your username and password. If you are a first-time
To authorise certain medication, the following may also
Emergencies
user, you will need to register.
need to be supplied:
• Go to ‘My Authorisations’ and click on the dependant code to
• medication details;
continue.
• the patient’s clinical examination data, e.g. weight, height, • Select ‘Chronic’ as the type of authorisation you want to update.
PMBs
blood pressure readings, smoking status and allergy
• Click on ‘Update’ and follow the easy ‘Online Chronic
information;
Application’ steps.
FAQ
Terms
Welcome
Contact
• Follow the prompts on the system and once all information has been captured
click on ‘View Summary’. You can print this screen for your records.
• Click on ‘Submit’ and a reference number will be provided for follow up on the
Membership
progress of the application.
The chronic application process has then been completed. You will get an immediate
response for the telephonic process, while the online process may take 24 to 48
Claiming
working hours to be processed. Where more clinical information is required,
members of the clinical team will review the information supplied and correspond
with you and your doctor either telephonically or in writing on the status of the
Selecting
medicine requested. You can follow up on the progress of your application at any
a PGP
time by contacting Sasolmed Customer Services.
Things to take note of:
Preventative
• Approved medication will be paid from the chronic medication benefit.
care
• You will still need to take your original prescription to the pharmacy or send it to
Medipost if you are using the Medipost courier pharmacy, for the dispensing of
Managed
your chronic medication.
care
• Once registered and your application has been approved, you will receive a chronic
authorisation letter listing the medication and conditions to be paid from your
Emergencies
chronic medication benefit. Note that some of the medication may not be listed, as
it will be paid automatically from the basket of drugs for the diagnosis authorised.
• If the medication authorised differs from the medication requested, an explanation
will be added to your authorisation letter.
PMBs
• The authorisation letter is not a prescription and cannot be used to have
medication dispensed.
FAQ
Terms
Welcome
• Your doctor determines the number of repeat prescriptions treating doctor, you will be able to go to your pharmacist
Contact
and will advise you how often he or she needs to see you to with a new prescription. If you have an authorisation for a
monitor your condition. condition, you will have access to a basket of pre-approved
• The duration of authorisation varies from medication to medication for your condition.
Membership
medication and diagnosis may be authorised on an ongoing
You only need to update us with your new medication, either
basis, whilst others may only be authorised for a limited
telephonically or online, as described above, if:
period. The chronic authorisation letter will indicate the
duration for which the medication or diagnosis has been • your medication is not in the basket; or
Claiming
authorised.
• you are diagnosed with a new chronic condition; or
• Please note that even if the medication or diagnosis is
• you need a quantity or dosage of a medication that is higher
authorised as ‘ongoing’, you still need to provide the
Selecting
than the quantity listed in the basket.
a PGP
pharmacy with a new prescription every six months, as
required by law. MRP and out-of-formulary co-payments will still apply to
medication that is pre-approved in baskets. Check the basket
Preventative
If your medication request has been declined
for your condition, as well as the formularies and MRP
care
• If any medication or diagnosis authorisation request has
information on the Member Zone at www.sasolmed.co.za or
been declined, e.g. if a less costly alternative or pathology
www.mediscor.co.za.
results are required, a letter of explanation will be sent to you
Managed
and a copy to the prescribing doctor. How prescribed minimum benefits (PMBs) affect the chronic
care
• Please ensure that the appropriate doctor provides the medication benefit
requested clinical information, where relevant. • The Chronic Medicine Management clinical protocols,
Emergencies
• Your doctor may also contact us on 0860 002 134 to discuss guidelines and formularies will apply as before.
the case. • However, out-of-formulary medication authorised by
• Your doctor can appeal a decision by submitting a clinical the Chronic Medicine Management Programme for PMB
motivation to chronic@sasolmed.co.za. conditions (according to Medical Council protocols) will be
PMBs
subject to additional co-payments as set out in the 2021
If your authorised chronic medication changes Benefit and Contribution Schedule.
FAQ
In most cases, where your medication is changed by your
Terms
Welcome
• In the formulary, PMB medication authorised by the Chronic
All other Applicable to cost of medication only
Contact
Medicine Management Programme, will be covered 100% REGISTERED
of the lower of single exit price of the Scheme’s Medicine chronic Approved • 90% benefit
Reference Price, subject to the MRP List, where applicable. conditions by Chronic (10% co-payment)
Medicine
Membership
Deductible member co-payments may apply. (non-PMBs) • MRP applies
Management
• Subject to annual
• Once the chronic medication benefit limit is reached, only Programme
chronic medication
medicine used to treat PMB conditions authorised by the
limit
Chronic Medicine Management Programme, that falls within
Claiming
the protocols specified by the Council for Medical Schemes, Out of • 70% benefit
will continue to be covered. formulary (10% co-payment and
20% out-of-formulary
• Formulary medication authorised by the Chronic Medicine
Selecting
co-payment)
a PGP
Management Programme to treat non-PMB conditions will
• Subject to annual
be subject to lower co-payments than out-of-formulary chronic medication
medicine. As such, you are encouraged to use medicine that limit
Preventative
is on the applicable formulary for your chronic conditions.
care
Not • Payable from acute
Your benefits for chronic conditions can be summarised as approved medication benefit,
by Chronic but subject to Scheme
follows:
Medicine rules
Managed
Management
care
26 chronic In formulary • 100% benefit Programme
diseases (CDL) • Unlimited; MRP applies
(now defined as
Emergencies
• All associated costs If you are unsure in which category your medication is
PMBs)
classified, please contact the Chronic Medicine Management
Out of • 80% benefit
formulary (20% co-payment) Programme.
• Unlimited; RMP applies You can read more about PMBs further on in this guide. The
PMBs
• All associated costs detailed benefits for medicine and other benefit categories,
are outlined in the 2021 Benefit and Contribution Schedule.
FAQ
Terms
Welcome
HOW TO COLLECT CHRONIC MEDICATION
If your doctor has prescribed chronic medication for your chronic condition, ask yourself:
Contact
To access your chronic How to register: Follow the steps provided above.
Membership
Have you medication benefits,
NO you must register a new
registered for
chronic medication condition.
for this condition
Claiming
before?
Your pharmacist can process your claim and
Go to your designated service
will provide you with feedback.
provider (DSP) pharmacy* with
Selecting
YES
a PGP
your new prescription.
You may need a motivation
from your GP, additional
Preventative
If you are approved for a chronic condition you will test results or to consider
care
have access to a list of pre-approved medication, a different medication.
called a basket. This means that if your doctor Discuss the reason for the What if my
prescribes a new medication for the condition, you rejection with your medication is
may already be approved for it. View the baskets GP or specialist. declined?
Managed
via the Member Zone at www.mediscor.co.za.
care
Emergencies
You can choose to pay for the medication
If your doctor changes If your medication is declined,
from your available acute medication
the medication on your your pharmacist will receive a
benefit or your own pocket. It won’t be
prescription, visit your reason and will advise you of
covered from the chronic medication
pharmacy. your next steps.
benefit if it is not approved.
PMBs
* If you have chosen the Restricted Network Option, Medipost Courier Pharmacy is your DSP. Visit www.sasolmed.co.za or the Sasol Intranet for the
FAQ
Medipost brochure and information on how to contact Medipost to order your chronic medicine delivery. Additional co-payments will apply for using a
pharmacy other than Medipost, if you have selected this option. You may also use Medipost to conveniently order your chronic medicine if you have chosen
the Comprehensive Network Option, but there is no additional co-payment should you obtain your chronic medication from a pharmacy other than the DSP.
Terms
Welcome
HOSPITAL PRE-AUTHORISATION
Contact
MANAGEMENT
A key component of hospital benefit management is the
Membership
pre-authorisation of hospital events.
What are the benefits of pre-authorisation?

The pre-authorisation process ensures added value for the
Claiming
member and the Scheme by assessing the medical necessity, as
well as the appropriateness of the planned intervention, before
the hospital event or admission.
Selecting
a PGP
Pre-authorisation offers the opportunity to:
• educate and empower the member; for example, should a
member not know what procedure a doctor was planning
Preventative
to do, a nurse would assist the member to establish what is
care
planned and in that way start to encourage the member to
take more responsibility for his/her own healthcare;
• pro-actively start ensuring that any proposed admission is
Managed
care
handled in the most appropriate and cost-effective way;
• pro-actively start planning for discharge; for example, an
Emergencies
elderly patient living alone might require home-nursing post
discharge – wherever possible, the Scheme starts making
these arrangements from day one;
• gather information; this not only facilitates the subsequent
PMBs
case management process, but provides the database for
managed care profiling and risk management tools;
FAQ
Terms
Welcome
• inform the member about specific limited benefits, co- • member or beneficiary name and date of birth;
payments and non-covered services or items, where • reason for admission (diagnosis) and applicable ICD-10 and
Contact
applicable; and tariff codes for the proposed treatment;
• pro-actively manage the funds of the Scheme and the • date of admission and date of the procedure, if applicable;
member’s benefits.
Membership
• name of the doctor and his/her practice number and contact
What does pre-authorisation entail? details;
• Confirmation of membership • name of the hospital, practice and contact details; and
• Evaluation of the request according to Scheme rules • in- or out-of-hospital indicator.
Claiming
• Evaluation of the request according to clinical guidelines and Once the above information has been captured, you will be
protocols issued with an authorisation number.
Selecting
a PGP
• Authorisation of hospital admission, where appropriate
If all the information has not been supplied or if further clinical
Momentum Health Solutions guidelines for admission, length of information is needed, you will be given a reference number.
stay and level of care are continuously updated and aligned with The Scheme will request the outstanding information from the
Preventative
international and local best practice. treating doctor.
care
Extensive use is made of evidence-based guidelines and Once all the required information has been obtained and it
protocols that are impartial, reliable and generally accepted. meets with the clinical protocols, your authorisation number
Managed
care
will be supplied.
How to pre-authorise a hospital event
• This process can be initiated by the member, medical For problem-free admissions
Emergencies
practitioner or the hospital.
• Notify us in advance, preferably by no later than 48 hours
• The request can be submitted telephonically, electronically
before admission.
(email or via the web) or by fax.
• You will be given an authorisation number that you need to
PMBs
The Scheme needs the following information to authorise provide to the hospital.
your treatment:
• membership number;
FAQ
Terms
Welcome
• The hospital pre-authorisation department will then be able
Contact
to manage your admission and monitor the care you receive
during your stay in hospital.
• If you do not get authorisation before going to hospital or
Membership
on the first working day following a medical emergency, your
treatment may not be covered and you could be held liable
for all costs associated with your admission.
• Only procedures that are covered in terms of the rules of the
Claiming
Scheme will be authorised.
Why are some requests declined?
Selecting
a PGP
Some of the pre-authorisation requests will be declined. There
are various reasons for this, for example:
Preventative
• the planned intervention is not covered by the Scheme, as
care
specified in the Scheme Rules;
• the planned intervention is not in line with the acceptable
treatment standards for a particular medical condition; or
Managed
care
• The membership of the beneficiary has been terminated.
Emergencies
PMBs
FAQ
Terms
Welcome
DENTAL MANAGEMENT What if I need special dentistry?
Contact
Contact Sasolmed Customer Services before undergoing any
What is preventative dentistry? special dentistry to confirm that you have benefits available
and that the procedure will be covered. A written treatment
Membership
Dental problems can result in a range of other health problems,
so it is important to your overall health to have regular dental plan and cost estimate from your dentist will help to determine
check-ups – don’t wait until you have a problem to go to the to what extent your available benefits will cover the procedure.
dentist. Sasolmed has designed the dental benefit to ensure
All orthodontic treatment must be pre-authorised
Claiming
cost-effective, quality dentistry, so be sure to use your dental
benefits to good and preventative effect. Benefits are also available for orthognathic (jaw) surgery,
subject to the availability of benefits. Pre-authorisation is
What if I need dental treatment under general necessary, and before undergoing this type of treatment, your
Selecting
a PGP
anaesthetic? healthcare provider must provide a motivation explaining the
Benefits are available for dental treatment under general medical necessity for the procedure.
anaesthetic or conscious sedation for children under the age of
Preventative
When will dental procedures not be covered?
eight years and for the removal of impacted wisdom teeth.
care
Dental Management examines claims according to clinical
Pre-authorisation is necessary for all procedures that require appropriateness using relevant dental coding and tooth
general anaesthetic or conscious sedation. Before undergoing numbers, where applicable.
Managed
this type of treatment, you must provide a motivation
care
explaining the medical necessity for general anaesthetic or Claims will not be paid for treatment that seem to be conflicting
sedation. Please obtain authorisation for hospitalisation at with your dental history or if the Scheme rules do not allow
Emergencies
least 72 hours before treatment, where possible. certain procedures. In such a case, your dentist will be asked for
a motivation, an amended account, or be sent a reason for the
In-hospital dentistry will be subject to a co-payment of R1 500 non-payment of the claim.
that will be payable at point-of-service.
Please check your annual benefits carefully, as co-payments
PMBs
may apply.
FAQ
Terms
Welcome
OPTOMETRY MANAGEMENT
Contact
Optometry Management provides you with clinically essential
optometric benefits that are financially validated. You have
Membership
access to optical benefits and products, as detailed in the
Sasolmed rules and according to preferential rates negotiated
with Opticlear network providers.
Claiming
What are the optometry benefits?
According to Sasolmed rules, the optometry benefit will provide:
Selecting
• benefits for comprehensive eye examinations;
a PGP
• benefits per beneficiary for single vision, bifocal or multifocal
(varifocal) spectacle lenses in glass and plastic; Plano (zero
Preventative
power) lenses for both eyes will NOT be covered by Sasolmed;
care
and
• hard contact lenses, conventional soft contact lenses and
disposable contact lenses, according to the benefits available,
Managed
care
including a specific benefit for keratoconus.
If a member chooses to use the services of a non-network
Which optometrists should I use? provider, Sasolmed will only reimburse the claims up to a
Emergencies
Sasolmed uses a preferred provider network of Opticlear maximum of the negotiated network rate. Members will
optometrists. This means that members can get clinically therefore be liable for any co-payments at the point of service.
appropriate benefits within limits, with no co-payments, if they
Please note that all benefits are subject to your available
obtain their spectacles from a network provider.
PMBs
benefit limits.
Visit www.opticlear.co.za for a list of Opticlear providers.
FAQ
Terms
Welcome
BACK AND NECK REHABILITATION PROGRAMME (DOCUMENTATION BASED CARE [DBC])
Contact
Second only to headaches in the ranking of painful disorders first. This will not apply to emergency admissions or prescribed
that affect humans, back and neck pain is a common cause of minimum benefits.
Membership
ill health and incapacity and is associated with significant social
and financial problems. To reduce your suffering and possible How can I access this benefit?
need for invasive surgery, the Scheme offers a conservative Contact Sasolmed’s Customer Services to confirm your benefits
back and neck rehabilitation Programme (DBC). and identify the Back and Neck Rehabilitation (DBC) centre
Claiming
closest to you.
Members enrolled on the programme will be identified for
either a physiotherapy programme or an intensive, six-week
Selecting
multidisciplinary programme where a medical doctor,
a PGP
biokineticist and physiotherapist are involved in the assessment
and treatment of your condition. This intensive programme is
provided at a DBC Clinic, which is one of the preferred providers
Preventative
for this programme.
care
The successful management of back and neck pain via the
Scheme’s conservative DBC Programme will improve your
Managed
quality of life and reduce your pain and suffering. The
care
programme is based on internationally successful care
pathways that reduce pain and stiffness and improve flexibility.
Emergencies
It is also proven to limit, avoid or postpone surgery. Where
surgery is truly warranted, this will be permitted within Scheme
rules.
PMBs
It is important that you understand that since the success
rate of this programme is very high, Sasolmed will not cover
surgery if the member has not gone for a DBC assessment
FAQ
Terms
Welcome
Contact
Membership
A NOTE ON PRE-AUTHORISATION:
In addition to the authorisation from the oncology
Claiming
management team, you will need to get pre-authorisation
from the hospital pre-authorisation department for any
hospitalisation services and specialised radiology (for
ONCOLOGY MANAGEMENT PROGRAMME
Selecting
a PGP
example, MRI scans, CT scans and angiography). Private
nursing and hospice authorisations must be obtained from
If you are diagnosed with cancer, it is important that you Oncology Management Programme.
Preventative
are immediately registered on the Oncology Management
care
Programme and that your treatment plan is forwarded to
the clinical team, as all oncology treatment is subject to pre- Please make sure that your doctor advises the oncology
authorisation and case management. management team of any change in your treatment, as your
Managed
authorisation will need to be re-assessed and updated. Failure
care
Once the oncology management team has received confirmation to do so may result in your claims being rejected or paid from
of your diagnosis and treatment plan, your details, disease the incorrect benefits, as there will be no matching oncology
information and proposed treatment will be captured. The
Emergencies
authorisation.
treatment plan is then reviewed and, if necessary, a member
of the clinical team will contact your doctor to discuss more How should I register?
appropriate or cost-effective treatment alternatives. After Your treating doctor should email a copy of your treatment plan
the treatment plan has been assessed and approved, an to the Oncology Management Programme (see contact details
PMBs
authorisation will be sent to you and your treating doctor. This earlier in this member guide). An oncology case manager will
letter will indicate the treatment authorised, the approved then take the process forward.
FAQ
quantities and the period of validity of authorisation.
Terms
Welcome
WEIGHT MANAGEMENT PROGRAMME part of the assessment enables the identification of specific
risk factors for metabolic syndrome and physical fitness for
Contact
exercise. A comprehensive health status report with tailored
Obesity is a complex disease that is dependent on many
recommendations for health improvement will be provided.
factors, including a person’s genetics and lifestyle. The current
Membership
understanding of how and why obesity occurs is incomplete; What should I expect?
however, it involves a combination of social, behavioural,
Once the assessment has been completed, an individualised
cultural, physiological, metabolic and genetic factors.
programme of appropriate exercises is constructed.
Claiming
Being overweight or obese substantially increases the risk of
The programme is managed by a BASA biokineticist and includes:
chronic conditions, including high blood pressure, abnormal
cholesterol levels, type 2 diabetes, coronary artery disease, • one to three one-on-one consultations with the biokineticist;
• nine weekly biokineticist-led group exercise sessions;
Selecting
stroke, gallbladder disease, osteoarthritis, sleep apnoea and
a PGP
respiratory problems, as well as cancer of the endometrium, • referral to a dietician and/or psychologist for two consultations
breast, prostate and colon. (initial assessment and follow-up), if necessary; and
Preventative
• monthly reports electronically submitted to your PGP and
The aim of the Weight Management Programme is to assist
care
medical scheme.
with weight loss through a comprehensive assessment and
exercise prescription by a BASA (Biokineticist Association of How much will it cost?
South Africa) biokineticist.
Managed
The cost of the programme will be covered by the Scheme’s
care
weight management benefits. Please note that this excludes
What will this programme entail?
the cost of any visits to your PGP, investigations or medication
Once referred to a BASA biokineticist, a full assessment will
prescribed by a medical practitioner, in which case acute benefits
Emergencies
be undertaken to determine suitability for the programme.
and Scheme rules will apply.
This would include an online lifestyle questionnaire, validated
biometric testing (blood pressure, cholesterol, blood sugar How do I enrol?
levels, height and weight [BMI]) and a fitness assessment. Contact Sasolmed’s Customer Services to register or for more
PMBs
information.
The fitness assessment includes waist-to-hip ratio, body fat
percentage, flexibility, posture and fitness measurements. This
FAQ
Terms
Welcome
YOURLIFE PROGRAMME (HIV/AIDS) to keep your condition confidential. The staff members at the
Contact
YourLife Programme have all signed confidentiality agreements
For most people HIV/AIDS is a frightening disease, but today and work in a separate area, away from the Scheme.
effective treatment is available that allows the majority of
Membership
Registration on the YourLife Programme
people living with HIV to lead healthy and productive lives
for many years. If your test shows you are HIV positive, Sasolmed strongly
recommends that you register on the YourLife Programme as
Action and information
soon as possible. Early registration on the programme ensures
Claiming
The first step is to find out whether you have been infected that you receive the most appropriate treatment and support,
with HIV and what you can do to protect your loved ones and meaning that you have an opportunity to lead a healthy,
stay healthy. Medication is available to suppress the virus, productive life for many years. Call them in confidence on
Selecting
a PGP
while good nutrition and exercise can play a critical role in 0860 002 134 and ask for an application form. Your PGP can
keeping your body strong and healthy. It is important to start also contact the YourLife Programme on your behalf and may
your treatment soon after diagnosis. Taking your medication also contact the medical team for advice.
Preventative
as prescribed will improve your quality of life and decrease
care
the risk of serious infections and other complications. Our After you have registered
YourLife Programme can help you access benefits that assist After you receive the application form, you and your doctor
you in managing HIV/AIDS. must complete it and return it to the YourLife Programme by
Managed
using the confidential contact details on the form. A highly
care
We can help you manage your condition
qualified medical team will review the information provided and,
Sasolmed has a benefit specifically for HIV/AIDS-related if necessary, discuss cost-effective and appropriate treatment
Emergencies
medication and tests. This benefit is used to pay for with your PGP.
medication to suppress the virus (antiretroviral medication)
and to protect against illnesses such as tuberculosis (TB) and Once treatment has been agreed upon, you and your PGP will
pneumonia, as well as regular monitoring tests. be sent a detailed treatment plan, which lists the approved
PMBs
medication and how to take them, as well as the regular tests
Your condition will stay confidential that need to be done to ensure that the drugs are working
HIV infection is a sensitive matter and every effort is made correctly and safely.
FAQ
Terms
Welcome
WHAT THE YOURLIFE PROGRAMME OFFERS YOU
Contact
The YourLife Programme provides a comprehensive and confidential HIV disease
management programme that offers both members and beneficiaries:
Membership
• medication to treat HIV (including drugs to prevent mother-to-child transmission
and infection after sexual assault or occupational exposure) at the appropriate
time;
Claiming
• treatment to prevent opportunistic infections like pneumonia and tuberculosis
(TB);
• regular monitoring of disease progression and response to therapy;
Selecting
a PGP
• regular monitoring tests to pick up possible side effects of treatment;
• ongoing patient support through our care co-ordinators;
Preventative
care
• best practice clinical guidelines and telephonic support for doctors by a team of
acknowledged clinical experts; and
• assistance in finding a registered counsellor for emotional support.
Managed
care
If you are exposed to HIV infection through sexual assault or needle-stick injury, please
Emergencies
ask your doctor to contact the YourLife Programme to authorise special antiretroviral
medication to help prevent possible HIV infection.
It is best to take this medication as soon as possible (within hours) after exposure. If the
PMBs
incident putting you at risk occurs over the weekend, make sure you get the necessary
medication on time. You or your PGP can contact the YourLife Programme on the Monday
morning to arrange authorisation of the drugs for payment by Sasolmed.
FAQ
Terms
Welcome
MENTAL HEALTH PROGRAMME
Contact
Mental health includes our emotional, psychological and social A telephonic helpline is available to any beneficiary suffering
wellbeing. Mental condition is a serious condition and can affect from a mental health condition or problems with substance
Membership
our thinking, mood and behaviour, as well as how we deal with (drug and alcohol) abuse. This provides you with direct access
stress. to a specialised care coach, who will assess your eligibility
for enrolment on the programme, explain the programme
Our Mental Health Programme has been built on the principle of and inform you about the benefits available to manage your
Claiming
providing support to both you and your family practitioner to condition.
promote access to the best quality primary mental healthcare
that is available. How to access this benefit
Selecting
a PGP
Simply call Customer Services on 0860 002 134 or email
The programme provides effective collaboration between family
mentalhealth@sasolmed.co.za to find out whether you meet
practitioners, psychiatrists and other healthcare professionals
the criteria for this programme. We use predictive modelling to
for example, psychologists and social workers and a specialised
Preventative
identify beneficiaries who could potentially benefit from this
care coach who will work together to ensure that members are
care
programme. Certain members and dependants may also be
supported in a way that suits their individual needs.
contacted to enrol on the programme.
Members who enrol on this programme will receive a care
Managed
How Sasolmed will cover the cost
care
plan to allow the member’s team of healthcare professionals
to optimally manage the member’s condition. This will be The cost of the programme is covered by the Mental Health
individualised based on each member’s unique requirements. Benefit. Please note, however, that this excludes the cost of any
Emergencies
Enrolled members can expect to receive relevant education, investigations or medication prescribed by a medical practitioner,
information on community support groups, plus an ear to listen in which case acute or chronic medication benefits will be used
and to provide support for any changes that are required. and Sasolmed’s rules will apply.
PMBs
FAQ
Terms
Welcome
ACTIVE DISEASE RISK MANAGEMENT PROGRAMME
Contact
The Active Disease Risk Management Programme identifies Sasolmed members registered on this programme have
members who are at risk of suffering complications or access to a health line where they can discuss their conditions
advancement of their chronic conditions. Sasolmed confidentially with registered nurses. These nurses will
Membership
automatically identifies and contacts members that we feel provide them with immediate, professional health advice and
would benefit from this programme. information. The nurses are not able to diagnose or treat health
problems over the phone and the advice provided does not
The programme helps these members to control, manage and replace a visit to your PGP.
Claiming
monitor their conditions. A team of qualified medical personnel
will provide them with relevant information and advice. With Please note that all information regarding medical conditions
their prior consent, we work together with their PGP to monitor is kept strictly confidential and is only known to the Active
Selecting
a PGP
their condition and treatment. Disease Risk Management team and treating doctors.
There are two levels of contact on this programme A handy online tool used by members on this programme is the
Personal Health Record, which can be used to see how healthy
Preventative
• One of our specialised care coaches will call identified members
they are and to share important medical information with
care
to fill in a screening questionnaire about their condition and
current treatment. After this we will provide educational their PGP to ensure that they receive the best possible care,
material on the condition and schedule a follow-up call. We especially in an emergency situation.
Managed
will ask for their consent to communicate with their PGPs. If
care
needed, we may refer them to a specialised care coach for a
specific condition.
Emergencies
• Our specialised care coaches, who are registered nurses, will
complete an intensive questionnaire with these members
and give them more detailed information. We will contact
them more regularly and monitor their condition actively to
PMBs
make sure they are following their treatment and taking their
medication as prescribed by their doctor.
FAQ
Terms
Welcome
MATERNITY MANAGEMENT PROGRAMME PAED-IQ BABYLINE: 0860 666 112
The Maternity Management Programme offers support to An exciting benefit for Sasolmed members is the telephonic
Contact
all moms-to-be throughout their pregnancy journey, as well helpline called Paed-IQ BabyLine, the first dedicated parent
as during their confinement in hospital. It provides guidance to advice line in South Africa.
the member should there be any complications or out-of-the-
Membership
ordinary costs. BabyLine is a child health advice line that offers clinical childcare
assessment and telephonic guidance. The service is available
Sasolmed beneficiaries who are registered on the Maternity 24 hours a day, seven days a week, 365 days a year – including
Management Programme will receive a welcome pack detailing weekends, public holidays and after hours. It is operated by
Claiming
benefit entitlements and baby registration procedures, and registered nurses in conjunction with the Department of
have access to an online pregnancy, childbirth and first-year Paediatrics at the University of Pretoria to ensure that members
care education portal. receive access to professional advice. BabyLine makes use of
Selecting
a PGP
well-established, standardised paediatric protocols that have
High-risk pregnant beneficiaries enrolled on the programme been formulated by some of the best minds in paediatrics world-
are identified and contacted regularly by their specialised care wide and are reviewed on a regular basis.
Preventative
coach. They offer support to the mom-to-be and information
care
to calm fears, deal with additional medical conditions, identify The following services are available:
complications early and guide them through their pregnancy. • home care advice;
• clinic/primary care/GP referral; and
Managed
care
• after-hours care.
Emergencies
PMBs
FAQ
Terms
8
IN THIS CHAPTER
EMERGENCY
• What should I do in an
emergency situation?
• What else can ER24 offer me?
MEDICAL • When will my costs not be

covered or will I not receive
SERVICES
the service?
• When should I call an

ambulance?
Welcome
WHAT SHOULD I DO IN AN EMERGENCY SITUATION?
Contact
084 124
Sasolmed has contracted ER24 as the emergency medical
services provider of choice. ER24 is one of the largest private
providers of emergency medical services in South Africa, with a
Membership
strong footprint in all major metropolitan areas. Should you be
involved in a medical emergency, call 084 124 and:
• telephonic trauma counselling and referral to specialised care
• tell the ER24 operator you are a Sasolmed member; the where needed in the case of:
Claiming
operator will ask you or the caller for all the information – hijacking;
they need to get help to you; – bereavement;
• the ER24 operator will guide you as to what to do until the – suicide;
Selecting
a PGP
ambulance arrives, e.g. CPR or controlling bleeding; and – poison/overdose;
• ER24 will provide emergency treatment and stabilisation – armed robbery;
at the scene of the emergency and transportation to the – kidnapping;
Preventative
nearest hospital.
– fire; and
care
TIP: Save 084 124 under ‘Emergency’ on your mobile phone for – assault, including sexual assault.
easy access.
WHEN WILL MY COSTS NOT BE COVERED OR WILL
Managed
care
WHAT ELSE CAN ER24 OFFER ME? I NOT RECEIVE THE SERVICE?
Sasolmed members also have access to: Kindly note that you have access to medically justified
Emergencies
ambulance transfers only and that transfers that are not
• ‘Ask the Nurse’ – a medical advice and information line for medically justified will be for your own account.
when you are not sure whether to call for an ambulance, see
your PGP or go to the pharmacy (it is important to note that Also, keep in mind that if you are transported to hospital by an
ER24 ambulance (even though approved), and on examination
PMBs
this is an advisory and information service only, as a correct
diagnosis cannot be made over the phone); and you are found to be fit enough to return home, you will be
responsible for arranging your own transport home.
FAQ
Terms
Welcome
WHEN SHOULD WE CALL AN AMBULANCE?
Contact
To help members understand when calling an ambulance is advisable and when it will probably just end up costing them money,
ER24 has put together the following handy comparison of emergencies versus non-emergencies. This will also help you to decide
whether a situation warrants a visit to a hospital’s emergency rooms or not. If you are uncertain whether a situation warrants calling
Membership
an ambulance, you can also call ER24’s helpline on 084 124 for advice.
NOT AN EMERGENCY: CONSULT YOUR

EMERGENCY: CALL AN AMBULANCE
PHARMACIST/PGP
Claiming
• When a person has, or is reasonably believed to have suffered, an • Only indication for use is availability of transport
acute injury or illness requiring medical attention and/or medical • Patient’s life or usual activities would not be
transportation by ambulance immediately threatened by referral to an alternative
Selecting
a PGP
• A doctor/registered nurse/paramedic has requested the urgent care facility for treatment at a later time
transport of a patient by ambulance • Non-urgent health need outside of usual office hours
• Acute life-threatening scenario • Alternative transport/home remedy is available
Preventative
care
Persistent shortness of breath/wheezing/ongoing chest pain that Coughs, colds, flu, bronchitis, earache or sore throat,
worsens with breathing; wheezing and difficulty breathing associated with or without fever or general weakness
with asthma with no response to usual medication
Managed
Acute or persistent, severe chest pain, especially if it radiates to the arm Ongoing, dull, nagging chest discomfort
care
or jaw and is accompanied by sweating, vomiting or shortness of breath
Sudden, severe onset of abdominal pain – the kind that makes it Abdominal pain caused by menstruation, constipation
Emergencies
impossible to walk and wakes one up in agony and/or other minor abdominal complaints
Difficulty speaking, confusion/altered mental state, weakness/paralysis, Fainting, dizziness and headaches in an otherwise
sudden loss of balance, especially with a history of high blood pressure; healthy person
in the elderly, sudden loss of vision, seizures or unconsciousness
PMBs
Fever: Above 40°C that does NOT respond to paracetamol and Fever: Under 38.5°C that responds to use of paracetamol
associated with all-over body rash; children under two months with and no rash
fever above 38.5°C
FAQ
Terms
Welcome
Contact
NOT AN EMERGENCY: CONSULT YOUR
EMERGENCY: CALL AN AMBULANCE
PHARMACIST/PGP
Ongoing, persistent diarrhoea and vomiting with dehydration; usually Diarrhoea and/or vomiting; patient able to walk around
Membership
more than eight episodes per day
Trauma: Deep cuts that require stitches, especially on the face and Trauma: Common sprains and strains, superficial cuts;
head, bleeding that won’t stop, large open wounds, broken bones/ bleeding stopped with pressure
dislocated joints, head injuries with loss of consciousness or eye injuries
Claiming
Severe testicular discomfort Painful urination and blood in the urine
Burns: Large surface area; burns to the face or a large part of the hand, Burns: Minor burns and scalding, small surface area
Selecting
where the burn encircles the limb; electrical burns
a PGP
Major allergic reaction: Breathing difficulties, swelling of lips/tongue or Minor allergic reactions: Watery eyes, runny nose, minor
throat, dizziness or fainting, rash and itching over entire body rash and itching
Preventative
Poisoning – accidental or intentional
care
Back pain after trauma, such as falling or less than three months after Back pain after heavy lifting; generalised back spasm
back surgery
Pregnancy – complicated Normal pregnancy/labour reached over 37 weeks
Managed
care
Before 37 weeks are completed, emergency determined, rupture of
membranes (waters broken), excessive bleeding during pregnancy,
contractions approximately five minutes apart, complication in
Emergencies
current or previous pregnancies, pregnancy-induced high blood pressure
diagnosed, crowning of the head
Suicidal thoughts expressed, sudden aggression/psychosis, previous Depression/emotional trauma
history of psychiatric admission, possible relapse requiring emergency
PMBs
admission
FAQ
Terms
9
PRESCRIBED IN THIS CHAPTER
MINIMUM • Why do we have PMBs?
• How do I access PMBs?
BENEFITS • How can healthcare providers

ensure payment of claims
(PMBs)
for PMBs?
• Council for Medical Schemes

article on PMBs
Welcome
WHY DO WE HAVE PMBs? To manage the treatment, medical schemes apply PMB
Contact
PMB legislation was created to ensure that all medical scheme formularies and protocols, which are largely based on the
members have access to continuous healthcare for specific government’s guidelines to manage these conditions. This is
conditions, even if a member’s annual limits have run out, referred to as PMB level of care.
Membership
regardless of the benefit option they have selected. Members
are entitled to at least the minimum specified treatment to
HOW DO I ACCESS PMBs?
manage their PMB condition. You need to use the same pre-authorisation process for
hospitalisation or chronic medication as explained under the
Claiming
PMB legislation requires the Scheme to provide benefits for the Hospital Pre-Authorisation Management and Chronic Medicine
diagnosis, treatment and care of: Management sections.
Selecting
• any emergency medical condition; and Once you have been identified as having a PMB condition, you
a PGP
• a list of 270 groups of conditions known as Diagnostic are given a clinically defined set of benefits based on State
Treatment Pairs (DTP), which includes 26 common chronic guidelines to manage your condition out of hospital, known as
Preventative
conditions grouped on the Chronic Disease List (CDL). a care template.
care
The costs related to the diagnosis, treatment and care of PMB HOW CAN HEALTHCARE PROVIDERS ENSURE
conditions are fully covered by medical schemes, provided a PAYMENT OF CLAIMS FOR PMBs?
member follows the guidelines.
Managed
The hospital, doctor or pharmacist must indicate on their
care
When deciding whether a condition is a PMB, the doctor should accounts that the treatment was for a PMB condition.
only look at the symptoms and not at any other factors, such
Specified codes (ICD-10) must be used by the healthcare
Emergencies
as how the injury or condition was contracted. This approach
providers to ensure that claims will be processed correctly.
is called diagnosis-based. Once the diagnosis has been made,
the appropriate treatment and care is decided upon, as well Chronic Disease List
as where the patient should receive the treatment, i.e. at a PMBs were introduced for specified chronic conditions from
PMBs
hospital, as an outpatient or in a doctor’s rooms. 1 January 2004. This list of 26 conditions is known as the Chronic
Disease List (CDL).
FAQ
Terms
Welcome
The 26 conditions are:
Contact
1. Addison’s disease (hormone imbalance) 14. Epilepsy
2. Asthma 15. Glaucoma (high pressure in the eye)
Membership
3. Bi-polar mood disorder 16. Haemophilia (bleeding)
4. Bronchiectasis (lung and airway disease) 17. HIV/AIDS
5. Cardiac failure (heart disease) 18. Hyperlipidaemia (high cholesterol)
6. Cardiomyopathy (heart failure) 19. Hypertension (high blood pressure)
Claiming
7. Chronic obstructive pulmonary disease (COPD) 20. Hypothyroidism (subnormal activity in thyroid)
8. Chronic renal failure (kidney disease) 21. Multiple sclerosis (neurological disease)
9. Coronary artery disease (artery obstruction) 22. Parkinson’s disease (brain disorder)
Selecting
10. Crohn’s disease (intestinal inflammation and obstruction) 23. Rheumatoid arthritis (auto-immune disorder)
a PGP
11. Diabetes insipidus (metabolic dysfunction of pituitary 24. Schizophrenia (psychiatric condition)
gland) 25. Systemic lupus erythematosus (skin and organ disease)
Preventative
12. Diabetes mellitus – type 1 (insulin dependent) and type 2 26. Ulcerative colitis (inflammation and ulceration of the
care
(generally non-insulin dependent) colon and rectum)
13. Dysrhythmia (irregular heartbeat)
Managed
care
Emergencies
Treatment of these 26 chronic conditions will be covered
in full by the Scheme. Legislation specifies, however,
that reimbursement will be subject to the application of
a formulary (a defined list of medication that Sasolmed
PMBs
will cover) and requires registration, as specified by
managed care.
FAQ
Terms
Welcome
COUNCIL FOR MEDICAL SCHEMES ARTICLE ON PMBs
Contact
Many members and even healthcare providers still don’t Your medical scheme may develop protocols to manage the use
understand how PMBs work, what benefits PMBs hold, and also of benefits. Such protocols would specify, for example, types
Membership
what the ‘dark side’ of PMBs is. The Council for Medical Schemes of tests, investigations and number of consultations. Members
put together a number of frequently asked questions to help who might need more frequent or extra services than provided
educate members on their rights and responsibilities in terms for in the protocols, can appeal to their scheme for these to
of PMBs. be covered. Your scheme’s appeals process might include a
Claiming
motivation from the treating doctor that explains the clinical
Why are some chronic conditions covered and some not? reasons for the additional services.
The conditions that have been chosen are the most common,
Selecting
Can my scheme refuse to cover my medication if I need,
a PGP
they are life-threatening, and are those for which cost-effective
treatment would sustain and improve the quality of the or want, a brand other than that which my scheme says
member’s life. it will pay for?
Preventative
Yes, the medical scheme may refuse to cover a part of the
Can my scheme insist that it will only fund treatment
care
expenses. Your scheme may draw up what is known as a
that follows the appropriate protocol? formulary – a list of safe and effective medication that can be
Yes. Treatment algorithms (benchmarks for treatment) for prescribed to treat certain conditions. Your scheme may state
Managed
all PMB conditions have been published in the Government in its rules that it will only cover your medication in full if your
care
Gazette. Your scheme may decide for which medication it will doctor prescribes a drug on that formulary. Generally speaking,
pay for each chronic condition, but the treatment may not be schemes expect their members to stick to the formulary
Emergencies
below the standards published in the treatment protocols. medication.
If your scheme’s cover conforms to that standard and you
and your doctor decide that you should rather use different Often the medication on the list will be generics – copies of the
medication, you may have to make a co-payment towards the original brand-name medication – that are less expensive, but
equally effective. If you want to use a brand-name medicine that
PMBs
cost of that medication. Your medical scheme must, however,
pay for the treatment if your doctor can prove that the standard is not on the list, your medical scheme may foot only part of the
medication is ineffective or detrimental to your condition. bill and you will have to pay either the difference between the
FAQ
Terms
Welcome
price of the medication you use and the one on the formulary, limit, regardless of whether or not it is one of the PMB chronic
Contact
or a percentage co-payment, as registered in the Scheme rules. conditions. However, if you exhaust your chronic medication
limit, your scheme will have to continue paying for any chronic
If you suffer from specific side effects from drugs on the medication you obtain for a PMB condition.
Membership
formulary, or if substituting a drug on the formulary with one
Source: www.medicalschemes.com/medical_schemes_pmb/questions.htm
you are currently taking affects your health negatively, you can
send a motivation to your medical scheme and ask them to pay
for your medication. You can also appeal to the Scheme if the THE ‘DARK SIDE’ OF PMBs
Claiming
formulary drug is ineffective. If your treating doctor can provide
Unfortunately there is a growing trend where providers
the necessary proof and the Scheme agrees that you suffer
abuse the PMB system, as they know that medical
from side effects or that the drug is ineffective, the Scheme
schemes must theoretically pay their costs, even if such
Selecting
must give you an alternative and pay for it in full.
a PGP
costs are much higher than medical scheme rates. Data
Can my scheme make me pay a co-payment or levy on a from various medical schemes indicate that providers
PMB? are starting to charge more for their services in the case
Preventative
of PMB conditions than for non-PMB conditions. The
No, your scheme cannot charge you a co-payment or levy on
care
reality is that providing cover for PMBs is costing medical
a PMB if you follow the Scheme’s formulary and protocol.
schemes more and more each year, with the inevitable
However, if your scheme appoints a designated service provider
result of contributions having to be increased by more
(DSP) and you voluntarily use a different provider, your scheme
Managed
than usual. This is also why medical schemes are very
care
may charge you the difference between the actual cost and what
strict in how PMBs are covered – should a member simply
it would have paid if you had used the DSP or the percentage
be able to claim the most expensive medication for a
co-payment, as registered in the Scheme rules.
Emergencies
given PMB condition, costs will soar out of control and
Can schemes still set a chronic medication limit? medical schemes will either have to charge exorbitant
contributions or no longer be financially sustainable.
Yes, your scheme can set a limit for your chronic medication
benefit. Any chronic medication you claim for will reduce that
PMBs
FAQ
Terms
10 IN THIS CHAPTER
• What are ICD-10 codes?
• Will I be covered for motor

vehicle injuries?
• What if I need a knee or hip

replacement?
• What should i know about fraud?
• What is benefit exploitation?
• What if I am unhappy
with service received from
Sasolmed?
• What is included in my
FREQUENTLY
member’s portion?
• What are co-payments and how
ASKED
can they be minimised?
• Why are certain emailed

documents password
QUESTIONS
protected?
Welcome
WHAT ARE ICD-10 CODES? diagnosis. Therefore, they require the diagnosis information
Contact
ICD-10 codes appear on healthcare provider accounts and are from your referring doctors so that their claims can also be paid
used to inform medical schemes of the conditions for which by the medical scheme, out of the correct pool of money.
members sought healthcare services so that claims can be
Membership
settled correctly.
WILL I BE COVERED FOR MOTOR VEHICLE INJURIES?
Motor vehicle accident (MVA) claims have certain procedures
ICD-10 stands for International Classification of Disease that must be strictly adhered to. PMB claims that are related
and Related Health Problems (10th revision). It is a coding to an MVA, however, are exempt from this procedure and
Claiming
system developed by the World Health Organization (WHO) subject to normal PMB protocols. If you are involved in a motor
that translates the written description of medical and health vehicle accident where a third party is liable, inform the Scheme
information into standard codes; for example, J03.9 is an as soon as possible. All accounts will be held until you have
Selecting
ICD-10 code for acute tonsillitis and G41.0 is used for epilepsy
a PGP
appointed an attorney to handle your claim from the Road
(unspecified). Accident Fund (RAF).
ICD-10 codes provide accurate information on the condition you
Preventative
The Scheme will assist you in appointing an attorney, provided
have been diagnosed with. These codes help medical schemes
care
that a written undertaking is submitted, signed by both the
to determine what benefits you are entitled to and how these member and his/her legal representative, confirming that
benefits should be paid. the Scheme will be refunded by the RAF for all claims that are
Managed
paid out by the Fund free of any legal fees. This will enable the
care
This becomes very important if you have a PMB condition,
Scheme to process claims timeously. Claims will be paid to the
as these can only be identified by the correct ICD-10 codes.
service providers, such as the hospitals and doctors concerned,
Therefore, if the incorrect ICD-10 codes are provided, your
up to the individual member’s limits.
Emergencies
PMB-related services might be paid from the wrong benefit
or it might not be paid at all if your benefit limits have been Cases that are rejected by the RAF will be covered by the
exhausted. Scheme up to the individual member’s benefit limits. However,
a letter will be required from the RAF stating that the claim has
PMBs
ICD-10 codes must also be provided on medication prescriptions
been rejected. Decisions will be made based on the rules of the
and referral notes to other healthcare providers (for example,
Scheme.
pathologists and radiologists) who are not all able to make a
FAQ
Terms
Welcome
The Scheme, which would have covered the medical costs on your
Contact
behalf, will have a claim against the RAF for medical expenses incurred
as a result of the accident. Therefore, the final settlement paid out
by the RAF for medical expenses will not be due to you and must be
Membership
refunded to the Scheme.
If you need to claim

To provide you with access to specialised support and assistance with
Claiming
lodging a third-party claim, the Scheme appointed Momentum Health
Solutions as Sasolmed’s provider for the recovery of all eligible past
medical expenses paid by the Scheme that may be recoverable from
Selecting
a third party.
a PGP
The arrangement will provide you with the following benefits:
Preventative
access to Momentum Health Solutions’ highly specialised
care
third-party claims team;
the option to appoint a reputable firm of attorneys to

institute a claim on your behalf, at preferential rates;
Managed
care
consultations with a member of the claims team by
appointment; and
Emergencies
the option to collect forms from, and deliver completed
legal forms to, Sasolmed’s walk-in branches and Client
Liaison Officers.
PMBs
Call 0860 002 134 for assistance with third-party claims and you will
be transferred to the legal advisors in the third-party claims team.
FAQ
Terms
Welcome
MORE ABOUT THE ROAD
Contact
ACCIDENT FUND (RAF)
Membership
If you are involved in a motor vehicle accident, you may qualify for
instituting a so-called third-party claim against the RAF to claim
compensation for past and future medical expenses, general damages,
loss of income and more.
Claiming
However, the process of instituting a claim against a third party is long
and cumbersome and often requires the appointment of an attorney. That
Selecting
is why Sasolmed wants to help you every step of the way.
a PGP
WHAT ARE MY RESPONSIBILITIES TO SASOLMED IF I HAVE
BEEN IN AN ACCIDENT?
Preventative
care
To help Sasolmed recover a portion of the millions of rand spent on
claims related to motor vehicle accidents, members have an obligation to
co-operate with the recovery process by disclosing all information relating
Managed
care
to a possible third-party claim and to sign all the required legal documents.
HOW SASOLMED MAKES IT EASIER FOR MEMBERS TO CLAIM
Emergencies
To provide you with access to specialised support and assistance with
lodging a third-party claim, the Board of Trustees appointed Momentum
Health Solutions as Sasolmed’s provider for the recovery of all eligible
past medical expenses paid by Sasolmed that may be recoverable from a
PMBs
third party. This will apply to all accidents from 1 June 2017.
FAQ
Terms
Welcome
WHAT TO DO IF YOU HAVE BEEN IN AN ACCIDENT legal rates with its contracted service provider. However, you
Contact
If you’re involved in any kind of MVA in which an outside person may still choose to proceed with a claim in your own capacity as
(‘third party’) was to blame, follow these steps: a direct claimant or through your own attorney at their normal
rates.
Membership
1 Get medical treatment
B. If you decide not to institute a claim
Sasolmed will cover treatment for injuries sustained in line with
If you decide not to institute a claim against a third party, for
Sasolmed’s rules and your available benefits.
instance, if your injuries were not serious and did not result in
Claiming
2 Call us on 0860 002 134 long-term physical impairment or a treatment plan, you will be
Ask for assistance with third-party claims and we’ll transfer you requested to cede your rights to claim against a third party to
to our legal advisers in the third-party claims team. Sasolmed. This will allow Sasolmed to institute a claim directly
Selecting
to recover the costs that were paid by Sasolmed.
a PGP
3 Complete an accident questionnaire and a member
consent and undertaking form Important: If you choose to use your own attorney to
Preventative
If you appear to have a valid third-party claim, you will be asked lodge your claim against a third party, Sasolmed and
care
to complete an accident questionnaire. This will help to ensure Momentum Health Solutions will have limited control over
the administration and progress made by your attorney
that you receive accurate advice and that the correct forms
on your claim. We will, however, regularly follow up with
are completed. You will also be required to sign a member
your attorney to record progress made.
Managed
undertaking, stating that you will pay Sasolmed back if you
care
receive a settlement that includes money that Sasolmed paid
on your behalf. WHAT WILL HAPPEN NEXT?
Emergencies
As soon as all the documents required for lodging a claim
4 Confirm how you wish to proceed against a third party have been submitted (either to Momentum
A. If you want to institute a claim Health Solutions, directly to the RAF or to a member’s attorney),
You can submit a claim through Momentum Health Solutions, Momentum Healthcare Solutions’ third-party recoveries unit
PMBs
the preferred provider rendering this service. You should be will ensure regular follow-up with the relevant stakeholders to
aware that Momentum Health Solutions has negotiated lower record progress, and will manage all requests for information
relating to copies of invoices relating to motor vehicle accidents.
FAQ
Terms
Welcome
We will regularly follow up with the third party in question and Please note that it is fraudulent to submit a claim to both
Contact
other stakeholders until a settlement has been reached and the RAF and Sasolmed for a refund. Double-claiming may
payment made, where successful. result in action being taken against you by the employer
and/or Sasolmed.
Membership
PLEASE NOTE: If you are required to consult with
practitioners in respect of an MVA claim, this will be MORE ABOUT WHAT YOU CAN CLAIM FOR
regarded as normal sick leave by the employer. You can institute a third-party claim:
• to recover past medical expenses paid by Sasolmed, as set
Claiming
WHAT MUST I DO ONCE PAYMENT HAS BEEN MADE? out in the Sasolmed rules that form part of your contract
with Sasolmed;
Members have 14 days from receiving the payment of an award
Selecting
a PGP
by a third party to notify and pay over (or instruct their legal • to recover past medical expenses paid from your own pocket;
representative on record to pay over) that portion of past
• to get an ‘Undertaking for future, associated medical and
medical expenses recovered and due for payment to Sasolmed.
other expenses’ from parties such as the RAF; this will ensure
Preventative
that you are always covered for potential future medical costs
care
WHAT IF I RECEIVE AN ‘UNDERTAKING FOR FUTURE
that you have to pay as a result of the injuries sustained;
MEDICAL EXPENSES’?
For many MVA claims, members will receive an ‘Undertaking • for general damages (such as pain and suffering), loss of
Managed
for future medical expenses’ from the RAF. Please notify the support and/or loss of earnings in the case of serious injuries
care
Sasolmed third-party recoveries unit if you receive such an sustained, subject to the requirements and provisions of the
‘Undertaking’. relevant Act; and
Emergencies
• to recover funeral expenses.
If we get your consent to claim on your behalf against an active
‘Undertaking’, it provides Sasolmed with a valuable tool to
recover money paid on your behalf, thereby contributing to
PMBs
the protection of Sasolmed’s available pool of benefits that are
accessible by all members.
FAQ
Terms
Welcome
WHAT IF I NEED A KNEE OR HIP REPLACEMENT? • consult with the DSP orthopaedic surgeon to determine
Contact
The Designated Service Providers (DSP) for Sasolmed knee and whether you meet the criteria for the clinical care pathway.
hip replacements are ICPS (Improved Clinical Pathway Services),
If you meet the criteria, an application for an authorisation
JointCare and CareExpert – three groups of orthopaedic surgeons
Membership
number will be arranged on your behalf by the administration
that specialise in performing hip and knee replacements
staff at the DSP practice. This will ensure payment in full, with
according to standardised clinical care pathways.
no co-payment for the procedure.
These care pathways have been developed in accordance
WHAT SHOULD I KNOW ABOUT FRAUD?
Claiming
with evidence-based outcomes to ensure that the quality of
the hip and/or knee replacement is of the highest standard Medical scheme fraud is a growing problem in South Africa and
and to ensure the best health outcomes. A multidisciplinary contributes to the increase in healthcare costs. Unnecessary
Selecting
team is dedicated to assist with rapid and successful recovery, and fraudulent expenses are funded by you, the member,
a PGP
keeping the patient as comfortable as possible during the through increased contributions. Sometimes service providers
healing period. commit fraud and other times the members themselves do
Preventative
so. In some cases, these two parties may even work together
For this reason, you must use the Scheme’s DSP for knee and to defraud a medical scheme so that they can both gain.
care
hip replacements to ensure that you do not incur a co-payment
for your surgery should you meet the necessary criteria. You can contribute towards the fight against fraud by carefully
and regularly checking your claims transactions and making
Managed
care
A R10 000 co-payment will be payable by the member for sure that you have not been involved in a fraud scam without
the voluntary use of a non-DSP provider for hip and knee your knowledge.
arthroplasties and/or replacement surgeries. In the case of an
Emergencies
emergency, the co-payment will not apply. While some incidences are quite obvious, in some situations
you as member may not even be aware that fraud is being
What to do if you need a hip or knee replacement: committed ‘in your name’. It is important to remember that
• call the Customer Services Centre on 0860 002 134 to be fraud – even the more ‘innocent’ cases – is illegal and that you
PMBs
provided with the details of a DSP orthopaedic surgeon may be prosecuted if you are found guilty of committing fraud.
closest to you; and
FAQ
Terms
Welcome
EXAMPLES OF FRAUD (In the case of service providers –
Contact
with or without the member’s knowledge and co-operation)
• Submitting claims for services that have not been rendered
(sometimes in return for a cash payment to the member).
Membership
• Manipulating claim codes to charge for a more expensive
procedure than the one provided, charging codes for services
not provided or claiming for services or products that are not
covered.
Claiming
• Providing services that are not necessary, simply to be able
to claim.
Selecting
• Dispensing low-cost generic medication, but claiming for
a PGP
more expensive brand-name medication.
• Providing fraudulent sick notes to members without even • Colluding with service providers, for example by forging
Preventative
seeing them and then claiming for a consultation. and submitting claims for services supposedly rendered by
care
healthcare professionals, but never actually rendered.
• In the case of pharmacies, selling cosmetics and other
non-medical items to Scheme members and then submitting • Altering amounts on invoices they have paid and claiming a
fraudulent claims for medication. higher amount.
Managed
care
• Doctors and hospital employees, with the collusion of the • Lending their Scheme card to people other than their
member, submitting claims for false hospital admissions. registered dependants to use.
• Where the member’s benefits has been depleted, holding
Emergencies
If you suspect that a service provider, colleague or any other
back a claim and changing the service date so that the claim person or organisation may be engaged in fraudulent activities
could be paid from the following benefit year’s benefits. against the Scheme, please contact the Fraud Hotline on
• When new members join, not disclosing previously existing 0800 000 436. You can also email the fraud hotline on
PMBs
medical conditions. sasolmed@tip-offs.com to report your suspicions.
• Belonging to (and therefore potentially claiming from) more
than one medical scheme.
FAQ
Terms
Welcome
WHAT IS BENEFIT EXPLOITATION?
Benefit exploitation costs medical schemes unnecessary money, which has an indirect effect on contribution increases. By
Contact
understanding what benefit exploitation is, and what it is not, you can help Sasolmed remain sustainable and avoid higher-than-
necessary contribution increases.
Membership
NOT BENEFIT EXPLOITATION BENEFIT EXPLOITATION
A healthcare provider sends a personal reminder A healthcare provider sends a blanket message to all patients, stating
to his/her patient to come for their six-monthly that their medical scheme benefits renew in January and that the
Claiming
check-up. This is clinical best practice and in the best member and their beneficiaries are encouraged to come for a check-up
interests of the patient. The reminder is not sent before their annual benefits run out. The message is only sent because
based on the patient’s medical scheme or benefit you belong to a medical scheme. Under these circumstances, there is
Selecting
a PGP
plan. The healthcare provider doesn’t care if you are no determination of medical necessity and the healthcare provider is
paying cash or claiming from a scheme, it’s in the targeting medical scheme members specifically for financial motives.
interest of your health to have a check-up. Using the benefit would be a waste of funds.
Preventative
care
WHAT IF I AM UNHAPPY WITH SERVICE RECEIVED Should you not be satisfied with the manner in which your
FROM SASOLMED? claims were processed and/or wish to lodge a complaint, the
Managed
escalation process to be followed is as follows:
care
Enquiring about a medical claim or receiving information on a
medical scheme issue should be a positive experience. Has a Contact Sasolmed Customer Services on 0860 002 134 during
customer service agent failed to provide you with feedback on office hours and try to resolve your query. If you do not consider
Emergencies
an existing enquiry or has your enquiry taken unnecessarily long the result to be satisfactory; then you can:
to be resolved? If so, you should contact Sasolmed Customer • send an email to enquiries@sasolmed.co.za, for the attention
Services and ask to speak to the team leader. By doing so, these of the Customer Services Manager, detailing the nature of the
escalations will be reported and trended to identify gaps and dispute; if feedback is still unsatisfactory; lodge a complaint
PMBs
improvement. in writing, for the attention of the Principal Officer, detailing
the nature of the dispute. The Principal Officer will convene
FAQ
Terms
Welcome
a meeting to adjudicate your complaint and/or dispute and WHAT ARE CO-PAYMENTS AND HOW CAN THEY BE
Contact
determine the procedure to be followed. You have a right to MINIMISED?
be heard at these proceedings if you so wish. A co-payment is a portion of the cost of procedures provided
• take your appeal further by approaching the Council for by doctors or medication prescribed, that members will be
Membership
Medical Schemes (CMS) for resolution, if you are still responsible to pay. The co-payment can be a set amount or a
dissatisfied after the decision made by the Committee. percentage of the total invoice, depending on the benefit type
They may be reached as per the contact information and limit. Not all healthcare services require a co-payment.
available at www.medicalschemes.co.za.
Claiming
Discuss the rates that are higher than the Scheme tariff with
your healthcare provider.
WHAT IS INCLUDED IN MY MEMBER’S PORTION?
Selecting
The member’s portion refers to expenses that are deducted Tips to minimise expenses
a PGP
from an employee’s salary or from a pensioner’s pension on • Ask for generic medication whenever possible.
a monthly basis or recovered directly from directly paying • Verify if your PGP is on the network. Check on the website
Preventative
members (DPMs). Co-payments that accrue to member portions locator or contact Sasolmed Customer Services.
care
include:
• Obtain a referral from your PGP before consulting a specialist
• a benefit that is not paid at 100% of Scheme tariff (for to avoid additional costs.
example, physiotherapy is paid at 80% of Scheme tariff, with • Check if small procedures can be done out of hospital instead
Managed
care
a 20% co-payment); or of in hospital.
• out-of-area general practitioner consultations exceeding the • Consider paying in cash and then claiming back so that you
three out-of-area consultations that are covered. can negotiate a discount.
Emergencies
• Get a quote before undergoing any procedure and check with
Any declined claims will not accrue to member portions.
Customer Services how much will be paid out to the service
provider.
PMBs
• Think twice about undergoing elective surgery procedures.
FAQ
Terms
Welcome
• If your doctor recommends a particular line of treatment and
you feel uncertain about whether it is necessary, request a
Contact
second opinion.
• If an operation is scheduled for the afternoon or evening,
arrange for hospital admission after 12:00.
Membership
• Make healthier choices to avoid or better manage lifestyle-
related chronic conditions.
• Use the screening tests and vaccines offered as part of your
preventative care benefits to prevent potential diseases.
Claiming
• Ensure that your chronic medication is registered to pay from
your chronic medication benefit.
Selecting
The password will be set to one of the following three default
a PGP
WHY ARE CERTAIN EMAILED DOCUMENTS
settings (in order of preference):
PASSWORD PROTECTED?
• Member’s ID number
Having to enter a password each time you open certain
Preventative
• If no ID number is available, the member’s passport number
documents is important to ensure your medical records are
care
must be entered
kept private and confidential at all times.
• If no ID number or passport number is available, the member’s
This step also forms part of the Scheme’s compliance with the date of birth [YYYYMMDD] must be entered.
Managed
care
Protection of Personal Information Act, No 4 of 2013 (POPIA),
If, for whatever reason, none of these options are available, the
which aims to ensure that all South African institutions
document is not password-protected.
conduct themselves in a responsible manner when collecting,
Emergencies
processing, storing and sharing personal information. Important
• If the Scheme does not have your ID/passport number or date
How to open a password-protected document from the of birth on file, you will not be able to open the attachment.
Scheme
• If you do not have an ID/passport number on file, kindly
PMBs
If you need to open a document from the Scheme that requires
email copies your ID and the ID or birth certificate of your
a password, simply type in the principal member’s ID/passport
dependant(s) to enquiries@sasolmed.co.za in order for us to
number or date of birth [YYYYMMDD] to open the document.
FAQ
update the system.
Terms
Welcome
11
Contact
EXPLANATION OF TERMS
Membership
TERM EXPLANATION
Claiming
Auxiliary (and Acupuncture, anthroposophical treatment, applied kinesiology, audiometry/audiology, autologous donation of blood,
paramedical) ayurvedic treatment, biokinetics, chiropody, chiropractic services, clinical technology, dieticians, herbalists, genetic
Selecting
services counselling, homeopathy, naturopathy, occupational therapy, orthoptic treatment, osteopathy, phytotherapy,
a PGP
podiatry, private nursing services, reflexology, speech therapy and social work.
Beneficiary A member and/or dependant registered with Sasolmed.
Preventative
Benefit year The period for which benefits and contributions apply – in this case 1 January to 31 December; if you join Sasolmed
care
during a benefit year, you are only entitled to a pro-rata portion of the benefits and limits for that year, i.e. in proportion
to the number of months of membership.
Child dependant For the purpose of calculating contributions, a child dependant rate will apply to a member’s child under the age of 23,
Managed
and an adult rate will apply from the month following the month in which a child dependant turns 23.
care
Designated A healthcare provider or group of providers selected by the Scheme as preferred providers to provide healthcare to
service provider Scheme members and beneficiaries; DSPs should be used exclusively by members for specific services, unless the DSP
Emergencies
(DSP) is not within a reasonable distance of the member, or in the case of an emergency.
Exclusions Services that are not covered in terms of the rules of Sasolmed.
Hospital benefits These generally cover the major medical expenses that you would incur when undergoing surgery or while in hospital;
PMBs
this does not include a visit to a hospital’s emergency rooms (ER), unless the condition warrants admission to hospital.
ICD-10 code International Classification of Diseases (ICD)-10 coding is a system that classifies diseases and the complications
connected to these diseases according to a specific category.
FAQ
Terms
Welcome
Medicine The list of medication used by Sasolmed, which excludes medication from payment from the acute medication benefit
Contact
Exclusion List for a number of reasons.
(MEL)
Medicine Price Amount payable by Sasolmed in respect of medicines. This amount is the sum of the single exit price (SEP) and
Membership
dispensing fee.
Member portion Any amount paid by Sasolmed on your behalf that exceeds the amount to which you are entitled.
Medicine MRP is a reference pricing system that uses a benchmark or reference price for generically similar products; the
Claiming
Reference Price fundamental principle of any reference pricing system is that it does not restrict a member’s choice of medication,
(MRP) List but instead limits the amount that will be paid.
Pre-authorisation The process whereby a member applies for approval for a procedure or treatment from Sasolmed; this may include the
Selecting
a PGP
submission of quotations; co-payments may be payable if you do not obtain pre-authorisation.
Prescribed The unlimited benefit to which all members are entitled, for treatment related to the conditions as specified in the
minimum Medical Schemes Act.
Preventative
benefits (PMBs)
care
Single exit price Price of medicine as determined by the State, and the manufacturer, at which it is marketed and purchased by the
(SEP) pharmacist.
Sub-limit The maximum amount of cover you have for specified medical expenses during the year.
Managed
care
Waiting period The period during which you will not be covered for any medical expenses incurred, even though you may be making
contributions to Sasolmed; there are two types of waiting periods:
Emergencies
Condition-specific waiting period: A period during which a beneficiary is not entitled to claim benefits in respect of
a condition for which medical advice, diagnosis, care or treatment was recommended or received within the 12-month
period ending on the date on which an application for membership was made. This will also apply to PMB.
General waiting period: A period during which a beneficiary is not entitled to claim any benefits; this will also apply to PMB.
PMBs
FAQ
Terms
Selecting Preventative Managed
Welcome Contact Membership Claiming a PGP care Emergencies PMBs FAQ Terms
care
www.sasolmed.co.za

(2192021123313 PM) Sasolmed Member Guide 2021 - Updated 15 Feb

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

(2192021123313 PM) Sasolmed Member Guide 2021 - Updated 15 Feb

Uploaded by

Copyright:

Available Formats

MEMBER GUIDE 2021

OWN YOUR TOMORROW

8. EMERGENCY MEDICAL SERVICES 60

WELCOME • What are my responsibilities as

• What is the role of the

• Sasolmed ‘SasChat’ and

• Electronic Health Record (EHR)

Sasolmed Customer Services – 0860 002 134 Hello Doctor

Email: dental@sasolmed.co.za (out of hospital) Submission of claims

Did you know that you can chat with

What are the benefits?

What are the features?

• Check your HealthSaver balance (if you have a HealthSaver

• Purchase medicine online

Office Park no. 9

OWN YOUR TOMORROW Sasolmed Member Guide 2021 | 13

Provider Search Documents Library

You can also use it to:

STEP 2: Click on the Electronic Health Record tab.

• Who can be registered

• Who is not eligible for

• How do I apply for membership

• How are my membership

• What should I do with my

MEMBERSHIP • What waiting periods will

WHO CAN BE REGISTERED AS DEPENDANTS?

Provident Fund: 100% of the contribution will be deducted via

OWN YOUR TOMORROW Sasolmed Member Guide 2021 | 19

A three-month general waiting period and 12-month condition-

OWN YOUR TOMORROW Sasolmed Member Guide 2021 | 21

• How can I help speed up my

• When can I expect payment?

• How do I submit an ex gratia

The Committee considers clinical outcomes when making a funding

• How do I select a PGP?

• What if my specific PGP is

• What if different members of

• What if we are on holiday and

• What if we have an emergency?

• What if I voluntarily consult

SELECTING A • Can I change my mind about

PREFERRED GENERAL • Who can register an additional

PRACTITIONER (PGP) • What if I need to see a

If you choose the Restricted Network Option (and particularly

Migrant workers (living Migrant workers must submit an

Members travelling The member involved in special

• visits to a paediatrician for children under one year of age;

• visits to optical and dental specialists; and

In case of an emergency, where a patient had to consult a specialist

• Why should I go for

• How can Sasolmed help me

OWN YOUR TOMORROW Sasolmed Member Guide 2021 | 32

7 • What is managed care?

• Chronic Medicine Management

• Hospital Benefit and pre-

• Back and neck rehabilitation

• YourLife Programme (HIV/AIDS)

• Active Disease Risk

• promote health and prevent disease; and

Sasolmed uses a dedicated managed care company,

This chapter explains how various benefits are

ACTIVE DISEASE RISK MANAGEMENT

OWN YOUR TOMORROW Sasolmed Member Guide 2021 | 38