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What is pre-authorisation and what does it entail?

Regardless of the type of healthcare plan that you subscribe to, you will have a clause that lists all of the medications and/or conditions that require pre-authorisation.

Pre-authorisation is also sometimes referred to as preapproval, prior authorisations and prior approvals. If you have ever been to an emergency room, or have been admitted to hospital, chances are that you have heard one or more of these terms being bandied about by the administration staff.

This means that in order for the hospital or specialist to administer either a certain type of medication, tests, or health services, your insurer or medical aid requires approval, usually given by a doctor, granting permission. Without this authorisation, your claim will be denied and you will be liable for any costs incurred.

Usually, when any type of authorisation is needed, the admin staff will facilitate this by calling the insurer or medical aid, although certain schemes allow patients to contact them directly.

Patient Advocate explains that an approved pre-authorisation is not a guarantee of payment. However, it is seen as a show of good faith between the insurer and the hospital; as an indicator of your health plan’s willingness to pay for the service or medication. And if you do have an approved pre-authorisation, your insurance is not promising to pay 100% of the costs. You are still responsible for your share of the costs, as you would any service or medication, including any co-payments or co-insurance set forth by your health plan’s design.

It is basically a nod for you and the hospital to take the next step in your care, while everything is being processed.

How does it work?

Usually, step one of getting healthcare will be going to your local GP. Then, the GP will examine you and if there is a need for further medical intervention, he will suggest that you be admitted to hospital; and this is the point where you will need authorisation. Either you will need it for full admission, or for a procedure that can only be done in hospital. This is sometimes also necessary for very expensive treatments (which may not be at the hospital) or medication.

Your insurance company will have requirements that need to be met before it will agree to cover the specific item or treatment.

Many times, this involves your doctor completing a form to illustrate your specific needs and to motivate certain selected treatments, says JDRF on-line.

Be sure to select a health insurance provider that covers your needs. Read the contract carefully to ensure that you are well aware of what needs authorisation and what your scheme does and doesn’t cover. Also, be aware of waiting periods that come with certain conditions and medications.

Affinity Health aims to make affordable healthcare available to all South Africans with healthcare plans designed to suit your health and financial needs.

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