The pre-authorisation process ensures added value for the member and the scheme by assessing the medical necessity and appropriateness of the procedure prior to hospital admission. This process can be initiated by the member, medical practitioner or the hospital. The request can be submitted telephonically, electronically (e-mail or via the web) and by fax.

Hospital Management Contact Information

Authorisations:
E-mail: preauth@mso.co.za
Tel: 086 000 2121
Fax: 086 636 9067

 

Send hospital accounts to:
Medical Services Organisation
Private Bag x 152
Braynston, 2021
Or drop off at:
Building 15 Healthcare Park
Woodlands Drive
Woodmead
Johannesburg

Or fax to: 086 636 9070
Or e-mail: preauth@mso.co.za

The pre-authorisation process is a part of Hospital Benefit Management and ensures cost-effective and appropriate use of health care resources when in hospital.

 

Pre-authorisation of hospital admissions includes:

– Confirmation of membership

– Evaluation of the request against scheme rules

– Evaluation of the request against clinical guidelines and protocols

– Authorisation of hospital admission where appropriate

Guidelines for admission, length of stay and level of care are continuously updated and based on both local and international best practice.

Medical Services Organisation uses evidence-based guidelines, which are impartial and reliable.

 

We need the following information to authorise your treatment:

– Membership number

– Member or beneficiary name and date of birth

– Contact details

– Reason for admission and applicable tariff codes for the proposed treatment

– Date of admission and date of the operation if applicable

– Name of the doctor and his/her practice and telephone number

– Name of the hospital, their practice and telephone number

Once the above information has been received, we will supply you with an authorisation number. However, if all the information is not supplied or if further clinical information is needed, you will be given a reference number and we will request the outstanding information from the treating doctor. Once this information has been obtained and it meets the clinical protocols, your authorisation number will be supplied.

 

The advantages of pre-authorisation:

– Educating and empowering you. For example, if you don’t know what procedure a doctor was planning to do, a nurse will assist you in establishing the details. This will help you to take take charge of your healthcare

– Ensuring that any proposed admission is handled in the most appropriate and cost-effective way

– Forward planning. For example, an elderly patient living alone might require home-nursing after discharge. Wherever possible, Medical Services Organisation starts making these arrangements from day one

– Information gathering. This assists with your case management and provides a database for Medscheme Health Risk Solutions profiling and risk management tools

– The opportunity to find out more about specified limited benefits, co-payments and non-covered services

– Helps us to better manage the funds of the scheme and your benefits

 

For problem-free admissions:

– Notify Medical Services Organisation (MSO) in advance – 72 hours before admission

– The authorisation nurse will give you an authorisation number and you must provide this to the hospital admission clerk

– The hospital benefit management department can then manage your admission and monitor the quality of care you receive during your stay in hospital

– If you do not get authorisation from us before going to hospital, or on the first working day following a medical emergency, your treatment may not be covered

– Only procedures that are covered in the rules of your scheme will be authorised

Why are some requests declined?

There are various reasons why certain pre-authorisation requests will be declined, for example:

– The procedure is not covered by the medical plan.

– The procedure does not qualify for funding from in-hospital benefits; instead it is funded from day-to-day benefits. In these cases, you will be referred to the client service centre for assistance.

– The procedure is not in line with acceptable treatment standards for a particular medical condition.

– Inactive membership status.

– Non declaration of a medical condition.