Understanding the healthcare jargon

What is a PMB (Prescribed Minimum Benefit)? 

PMBs refer to a list of 270 Chronic Disease List and emergency medical conditions which, by law, all medical schemes are required to fund. It is important to note that PMBs are very specific conditions and that not all sub-categories of a condition may be a PMB. The Scheme can also require that you receive care at a designated provider or are moved to one as soon as you are stable in emergency cases. Non-designated providers are only covered at the rate at which designated providers are paid. 

Click here to view the full list of PMBs

What is a Modifier? 

A modifier is coding to give us more information about a specific procedure and enables a physician to report or indicate that a service or procedure that has been performed has been altered by some special circumstances, but has not changed in its definition or code.

What is a Basket of Codes (BOC) and who decides on these baskets?

A Basket of Codes (BOC) is a representative basket of what the Scheme covers unless pre / post authorised. The Managed Healthcare Department in conjunction with the Scheme Rules / Principles as well as the Scheme decide upon these baskets. Codes in a basket are decided upon by the Scheme and comprise of all that is required for the procedure to take place. Additional codes / procedures done will not be covered as it does not fall in the funding / basket of codes as per the Scheme Protocols and benefits.

Please explain 100% of Scheme Rate

The Scheme Rate refers to the rate the Scheme allocates for a specific tariff or relevant health service. It is determined annually based on the pricing recommendation published by the Council of Medical Schemes (CMS) in 2009, with annual CPI adjustments. The Scheme Rate is the maximum rate at which non-contracted providers will be funded, including for Prescribed Minimum Benefit (PMB) conditions.

What is a co-payment?

A co-payment is a percentage or partial rand amount of a claim which the member concerned is required to pay from his / her own pocket. Co-payments can take the form of either a fixed payment before having certain procedures done, or a shortfall experienced due to using a non-network provider.

What is a medicine formulary?

A medicine formulary is a defined list of medicines used in the treatment of diseases. Each option and condition has its own formulary.                    

What is a Letter of Motivation (LOM)? 

An LOM is a letter from your treating doctor motivating why a specific treatment, or medication is required.

What is an RAD (Radiology Report)? 

A RAD report accompanies your scans or x-rays, and is provided to your doctor by the radiologist. The Scheme may request these reports before providing pre-authorisation.

What is the Chronic Disease List (CDL)?

CDL refers to a list of 25 chronic diseases that form part of the Prescribed Minimum Benefits (PMBs). Click here to see what they are.

What does To Take Out (TTO) stand for?

TTO stands for to take out (home) and is medication dispensed by your doctor for you to take home upon discharge from hospital.                    

What is Patient Driven Care™ (PDC™)?

PDC™ is our unique way of helping our at-risk chronic members manage their health and benefits better so that they’re always able to get the care they need, when they need it most.

What is the NHRPL?

The National Health Reference Price List (NHRPL) is a guideline set out by the South African Medical Association which outlines the rates at which medical providers may charge for their services and which medical schemes use to negotiate tariffs.

What is a Designated Service Provider (DSP) and why should I use one?

 Medical Schemes have Designated Service Providers (DSPs) which are a set group of preferred / designated healthcare providers from whom members can obtain diagnosis, treatment and care at negotiated and cost effective rates. A DSP is usually a treatment centre, hospital or pharmacy.  By using a DSP members can obtain co-payment free, unlimited diagnosis and treatment in respect of Prescribed Minimum Benefits (PMBs). Find a DSP near you

What does Level of Care (LOC) mean? 

LOC refers to the type of care which your medical provider recommends for you e.g. hospitalisation, ICU etc.

What does Length of Stay (LOS) mean? 

LOS refers to the amount of time you spend as a patient in hospital.