Hassle Free Medical Aid Approval

Pre authorisation

As part of our service, CHi will assist you to obtain authorisation from your Medical Aid for hospital admission, as well as for the relevant procedures. This will help to ensure that you receive the quality of healthcare that you deserve – without the hassle and stress of having to deal with the Medical Aid.

Pre-authorisations give you the confidence of knowing that once this has been done, the claim process after your surgery should also be hassle free.

Information needed for pre- authorisation

The following basic information is required to obtain timeous pre-authorisatiuon:

  • Treatment date – When you are being admitted and when the procedure is taking place.
  • Membership number – your Medical Aid number as well as the beneficiary identity (main member or one of the dependent beneficiaries).
  • Your ENT surgeon’s name and practice number.
  • The name and practice number of the hospital where your surgery is taking place.
  • Diagnosis and procedure codes – this tells the Medical Aid why you are having the procedure at all.
  • In- or out of hospital procedure – whether you are being admitted to hospital or being treated in the doctor’s/audiologist’s rooms.

Clinical data

Your CHi ENT surgeon will ensure that your motivation to your Medical Aids contains all clinical information that its Medical Review Team will require in order to assess your pre-authorisation request.  Should the Medical Review Team request any additional information, this will be made available but it could prolong the authorisation process.

The request for authorisation, accompanied by the supporting documentation, should reach the Medical Aids with ample time to review the request and make a decision timeously and according to the scheduled date of procedure.

Authorisation number

When the request has been reviewed and approved, you will receive an authorisation number from the Medical Aid. Be aware, however, that an authorisation number is not a guarantee of payment – your Medical Scheme’s rules always apply. However, obtaining authorisation well in advance will give you time to make the necessary arrangements should there be a possible shortfall in the amount your Medical Aid will contribute in terms of your Medical Aid rules and plan option.

Medical Aid and Plan Option

While the basic information outlined above plays a vital role in obtaining authorisation, factors such as which Medical Aid you are a member of and your Plan Option also determines whether you will obtain approval for the procedure and how much of it will be covered. Most Medical Aids have a prosthesis benefit which helps with payment. There are some Medical Aid schemes which are more likely to provide full or a high level of reimbursement for an implant procedure. But even within those Medical Aids, the plan type you are on can make a difference.

Be aware that while a Nappi code may be on a Medical Aid’s approved product list, this is no guarantee of authorisation for the procedure: the final decision will be based on the relevant procedure codes you will require and your Plan Option.

It is therefore advisable that you request authorisation for each procedure individually – and provide all the relevant documents required for each procedure.

Many Medical Aids have partnered with specific providers and networks to ensure in an effort to contain healthcare expenses, and to reduce your risk of liability for any unforeseen co-payments. CHi is a registered provider to most of the major Medical Aid Schemes.