In this episode we explore Prescribed Minimum Benefits and how to claim these from medical aids. One of the of the reasons why PMB claims are rejected is the incorrect coding for diagnoses that are specified in the Medical Schemes act. We will talk about the diagnoses that are covered (including the ICD-10 codes), and which are not. We will also talk about other reasons why claims get rejected – eg. specified waiting periods, or other documentation that needs to accompany certain codes. We will also talk about various claim procedures for some of the major medical aids.
References:
List of PMBs and ICD-10 codes: https://www.medicalschemes.co.za/resources/pmb/pmb-conditions/
ICD 10 Data (2021) Mental, Behavioral and Neurodevelopmental disorders
Retrieved from: https://www.icd10data.com/ICD10CM/Codes/F01-F99
Medical Schemes Act (131 of 1998) Retrieved from: https://www.medicalschemes.com/files/Acts%20and%20Regulations/MSACT19July2004.pdf
Moodley, N. (2021, 3 November) How to master Prescribed Minimum Benefits to ensure you get the most out of your medical schemein Daily Maverick Retrieved from: https://www.dailymaverick.co.za/article/2021-11-03-how-to-master-prescribed-minimum-benefits-to-ensure-you-get-the-most-out-of-your-medical-scheme/
Mngadi P, Wolvaardt J, Thsehla E. (2019) Agreeing on the minimum: An 11-year review of Prescribed Minimum Benefits appeals. S Afr Med J. Jun 28;109(7):498-502. doi: 10.7196/SAMJ.2019.v109i7.13683. PMID: 31266576.
South African Depression and Anxiety Group (2020) Prescribed Minimum Benefits and Chronic Medication Retrieved from: https://www.sadag.org/images/pdf/pmb_consumerguidebooklet.pdf