The authorisation process entails assessing the clinical necessity and appropriateness of the referral, procedure or treatment according to the Scheme’s clinical protocols and guidelines, prior to the specialist visit, hospital admission or treatment.
Members should also confirm their benefits prior to any of the abovementioned instances, to ensure the claim is funded from the correct benefit. Full funding is determined by availability of benefits and utilisation of designated service providers (applicable to PlatComprehensive and PlatCap Options).
Although we check if a member is eligible for treatment and that sufficient benefits are available to cover costs, an authorisation is not an automatic guarantee that claims will be paid. You are encouraged to ask for details about how much will be paid by the Scheme when requesting authorisation for non-emergency procedures such as specialist consultations, planned in-hospital procedures and medical admissions, special radiological investigations such as MRI, CT and PET scans and managed-care programmes such as maternity and oncology.

WHEN IS AUTHORISATION NEEDED?