Know how medical aid authorisations work

In hopes of eliminating confusion, Shaney Britoe, an oncology case manager, sheds some light on the medical aid authorisation process by answering frequently asked questions.

What are authorisations?

Authorisations are the pre-approval of a specific drug, service or admission, prior to the date of service to ensure payment from a particular benefit within your medical aid. 

Remember that an authorisation is not a guarantee of payment but only a confirmation of benefits at that particular time, subject to availability of funds or benefit.

I’m registered for oncology, why do I still need to get authorisation?

Note, oncology registration can only be done by the treating oncologist or  case manager submitting a tissue diagnosis (histology report of a biopsy, resection or fine needle aspiration) to your medical aid.

So, even though you have been registered, it’s still imperative that pre-approval is sought before any service or treatment is commenced for three reasons: 

  1. Though your medical aid allows a certain amount of money per annum, it will only pay in accordance with its scheme rules, and it adheres to guidelines in South Africa to ensure a standardised treatment platform for oncology. South African schemes adhere to one of two protocols: Independent Clinical Oncology Network (ICON) or South African Oncology Consortium (SAOC). 
  2. By obtaining approval, your medical aid is able to assist you and your doctor in managing your funds to ensure adequate treatment and benefits per annum. 
  3. To ensure you have access to the required treatment/service and will not end up having to self-fund it.
How do I go about getting authorisation?

This is the more intricate part. Any oncology treatment or service (radiology, blood test) falls into one of three tiers:

  1. Tier 1 – Prescribed minimum benefits (PMB). This is the primary level of care and is available in the public sector.
  2. Tier 2 – This is the standard of care for the particular condition and can include both Tier 1 and Tier 2 modalities.
  3. Tier 3 – The ‘real fancy stuff’ like mono-clonal antibodies, immunotherapy, unregistered drugs and specialised radiology e.g. PET-, octreotide-, dotatate scans etc.

Once registered for oncology, you have access to certain blood tests and conventional radiology without approval, such as X-rays/ultrasounds. However, the specialised radiology, like CT- or MRI scans, you will need authorisation. This is usually done telephonically. 

Treatment authorisation

For treatment, however, a full treatment plan must be submitted to  the scheme. Whether a telephonic or written submission, the following details are needed:

  • Patient’s full names as on ID document
  • Date of birth
  • Date of service/or start date of treatment
  • Confirmation of tissue diagnosis e.g. histology report
  • Confirmation of stage of cancer e.g. radiology reports
  • ICD 10 code (diagnostic code) 
  • Cost of treatment or service
  • Nappi codes for treatment or procedure codes for services.
  • Service provider’s practice number and for radiology – the referred providers as well.
  • If the requested services or treatment is Tier 3, it must be accompanied by a letter of motivation and clinical data in support of the request. Your doctor can advise you on which Tier the treatment/service is.

Treatment authorisation is usually done by the case manager/ authorisation clerk at the service provider. Though, sometimes the patient will have to do their own telephonic authorisations.

What is the big hype around PMB?

PMB is the primary level of care for a specific condition. This can be treatment and services. If your condition and treatment fall under PMB, your medical aid must continue to pay and in full, even if you have depleted funds. Speak to your doctor or case manager to find out if you can be flagged for PMB.

How can I appeal a previously declined request?

This can be difficult but is certainly possible. Once a request has been declined, you can appeal this decision. The best way is to obtain a letter of motivation from your doctor along with clinical data, like clinical trials; a letter of motivation by yourself, spouse or close relative, and submit with your treatment plan and request for it to be reviewed for payment by method of exception. 

Address this to the medical advisor and always mark it urgent. If this fails on clinical grounds, you can further appeal and request that an external panel review your appeal.

If it’s declined as a general scheme exclusion, you can then appeal to the principle officer. 

In the event of an unreasonable decline, you can lodge a complaint with the Council For Medical Schemes (CMS) for intervention.

Can I get an authorisation for a service already rendered?

The general rule is that an authorisation be obtained prior to service, or if the service or admission is over a weekend, that it be done on the first working day thereafter. However, in certain instances, it’s possible to send a treatment plan and request that it be backdated to the date of service to ensure funding over that time. This can be done, provided it be done within the general claim period (four months).

Is there any way I can have co-payments wavered?

There are only three ways this can be done:

  1. If your condition and treatment fall under PMB.
  2. You can apply for ex gratia but will have to prove that you cannot afford the co-payment and that there is no alternative treatment available.
  3. There are programmes that assist patients with co-payments but these are only available for certain drugs:

A) Access to Innovative Care Foundation (AICF) assists with certain drugs used in breast-, colon-, kidney-, ovaria and brain cancers.

B) Savanti Care assists with certain drugs used in breast-, colon-, rectal-, haematological and neuroendocrine cancers. Enquire by emailing [email protected]

Turn-around times

The time frame changes from  medical aid to medical aid and per request. Generally, a standard treatment plan takes two to seven working days to be reviewed and approved (depending on which medical aid it is). An out of protocol request can take up to a month as different panels will review the case. An ex gratia request can take up to six weeks before a decision is finalised.

Crucial questions to ask when joining/upgrading a medical aid
  1. Do I have access to treatment over and above just PMB?
  2. Can I get access to specialised drugs and radiology?
  3. Is there a separate specialised drug benefit?
  4. Which protocol does the option fall under – SAOC or ICON?
  5. Can I see any specialist and be admitted to any hospital?
What about waiting periods?

When joining a new medical aid, there may be waiting periods from three to 12 months before certain services are accessible. It’s important that you declare your conditions when joining, as non-disclosure can lead to termination of your membership. A good thing though, is that if your condition and treatment fall under PMB, the waiting period must be wavered.

A good website to visit is the Council for Medical Schemes ; there are constant updates on new scheme regulations, scheme contact details and that of the principal officers.

Know the lingo

  • PMB: a set of defined benefits accessible to you regardless of the option or medical aid you’re on.
  • ICD 10 code: diagnostic code, each condition and symptom has one e.g. C50.9 – breast cancer.
  • Nappi codes: drug billing code, each different drug and different strength has an item code, called the nappi.
  • Clinical grounds: a decision made based on the clinical appropriateness of a drug or service.
  • General scheme exclusion: drugs or services that your scheme does not cover. These auto-decline without review.
  • Unreasonable decline: when your request is declined without clinical consideration or a valid reason.
  • Ex gratia: the allowance of additional benefits or money, payment by exception and not rule.
  • Standard treatment plan: a treatment in accordance with the ICON or SAOC guidelines.
  • Out of protocol request: a treatment request that does not adhere to ICON or SAOC guidelines.
  • An ex gratia request: a request for additional benefits to pay as an exception.

MEET OUR EXPERT – Shaney Britoe

Shaney Britoe is a case manager at Sandton Oncology. She gained interest in oncology whilst working at Lancet Laboratories (oncology division). She has worked at Donald Gordon Oncology Centre, Rosebank Oncology, and SAMHS medical aid administrators.