None of us ever want to fall sick or be treated in a hospital.
But in the unfortunate event that you or one of your loved ones need to receive medical treatment in a hospital, please take note of the following important information.
Genesis Medical Scheme does not “authorise” treatment for any admission to hospital. Instead, we will issue a hospital admission reference number.
“Why not pre-authorise?” you may ask?
It is because the Scheme may not and does not provide any medical service or treatment to members; nor does it interfere with any clinical decisions or protocols made by or recommended by your doctor(s). The Scheme’s role is solely to provide funding for the treatment and service(s) you receive whilst in hospital on the basis set out in the rules.
To obtain a hospital admission reference number for booked/planned procedures/treatment, please contact us on 0860 10 20 10, three (3) working days prior to admission and provide the following information:
- Your membership number;
- When you / your dependant will be admitted to hospital;
- Date of the procedure;
- Estimated duration of the hospital stay;
- Your treating doctor’s name, practice number and contact number(s);
- Your diagnosis (your doctor must provide you with the relevant ICD-10 and procedure codes); and
- Name of hospital / clinic.
If it is a first time admission, please contact the Scheme as soon as you become aware of the admission, as the Scheme may conduct a Medical History Review, in which instance three (3) working days may not be sufficient.
Musculo-skeletal surgery requirements
Where musculo-skeletal surgery is required (in other words, surgery that is performed by surgeons specialising in orthopedics), the Scheme may require the following additional information:
- Input from the operating surgeon as to why surgery is indicated;
- Copies of recent scans and / or X-rays;
- Confirmation of previous conservative treatment;
- Report from physiotherapist; and
- Quotes relating to the prosthesis and service providers (e.g. the hospital, surgeon and anaesthetist).
Medical History Reviews (MHR) in relation to reference numbers
The Scheme may in certain instances elect to conduct a Medical History Review (MHR) before a hospital admission reference number is released. A MHR is usually done to obtain full details of your (or your dependants) medical history prior to joining the Scheme, especially when a hospital admission request is received shortly after joining the Scheme and where the treatment that is required, has no reference to any medical condition disclosed on your application form, or if it is a first time admission with Genesis. In this case the reference number will be PENDED. Although the Scheme makes every effort to conclude the review as speedily as possible, it is often out of our hands and we cannot release the reference until the review is concluded. This is for this reason that is recommended that you notify us, where possible, well in advance of a first time admission.
What about emergencies?
In the event of an emergency, or after hours / over weekends, you must notify the Scheme by no later than the first working day following such hospital admission.
The fact that Genesis issues a hospital admission reference number for an intended treatment and / or procedure(s) is not a guarantee of payment or reimbursement of any claim submitted. The reimbursement of all claims is always subject to adjudication and audit in accordance with the benefits provided in the Scheme Rules.
This means that Genesis will reimburse the costs for treatment in accordance with the Scheme Rules. The hospital costs will be reimbursed at the scale of benefits (which usually means at the rate at which the hospitals charge the Scheme). The doctor(s) and other service provider costs will be reimbursed in accordance with the Scheme Rules applicable to the benefit option that you are on. Service providers may charge more than the reimbursement rate applicable to your benefit option. It is important to remember that doctors may not be employed by private hospitals and so they charge a fee separate from that of the hospital.
All consultations, procedures and / or special investigations done on the pre-operative day and for which a hospital facility is not necessary, will at the Scheme’s discretion, be reimbursed from your savings account or SMF facility (if available), or will be for your personal account.
Prescribed minimum benefits (PMBs) as prescribed in the Medical Schemes Act will be reimbursed as prescribed in the Act. For more information in this regard, give us a call.
Read our Blogs on funding for hospital admissions
Although your hospital costs (e.g. theatre cost, ward fees, meals, consumables such as drips, needles, bandages and the like, nursing care, medicines, etc.) will usually be reimbursed in full by Genesis, this does not mean all costs relating to a hospital admission will be covered in full.
To understand the funding role of Genesis, we encourage you to also read the below series of articles, which provide valuable insight and understanding of the funding applicable to your hospital event.