Hospitalisation Authorisation Procedure

Members have to obtain authorisation from Case Management for any planned hospital admission or procedure in a hospital, at least two (2) days prior to being admitted to hospital. In case of emergency admissions, authorisation has to be obtained within 24-hours or on the first working day after the emergency.
In the event of emergency treatment or admission to hospital over a weekend, public holiday or outside normal working hours, you must contact the Scheme for authorisation on the first working day after the incident. If you do not obtain authorisation for a planned event, or fail to authorise hospital treatment on the first working day after an emergency event, your claim may be rejected for payment. Any admission or outpatient visit to a hospital, must be authorised.

If your hospital stay is longer than expected
Any additional days in hospital, multiple procedures or additional services require further authorisation or motivation. Please arrange that your doctor, the hospital case manager or a family member, inform the Scheme of the extended length of stay. If there is a clinical reason for the extended stay, the Scheme will approve the extra days. If not, the member will be responsible for the cost for the non-approved days and treatment.
Once the authorisation request has been approved, you will receive the following information:

The unique authorisation number
The approved dependant
The approved supplier
The initial length of stay
The status of all the codes (whether approved or rejected in accordance with the Scheme Rules)

REQUEST AUTHORISATION

ADMISSION IN DESIGNATED SERVICE PROVIDER (DSP) HOSPITALS

General Practitioner/Specialist issues a request for referral

Member has to consult the General Practitioner (GP)/Specialist with a specific condition/problem and the specialist referral process has to be followed.
The GP/Specialist completes a request for admission and gives it to the member. The member should use this request to obtain authorisation for the hospital admission from Case Management.
The hospital authorisation request from the GP/Specialist should contain the following detail:
The patient’s
- Name
- Date of birth
- Medical scheme number
- Contact details
The hospital details and practice number
The admitting/treating GP/specialist’s details and practice number
Admission date
Diagnosis
ICD 10 code

If a referral is approved

Case Management evaluates the reffering request with the assistance of the Medical Advisor and authorises the admission.
Member receives an authorisation number via SMS, email, telephone or from Platinum Health facility.
Hospital authorisation request/pre-admission documents need to be send or taken to the hospital before admission date. This is to ensure pre-admission documentation is completed and captured on the hospital system to ensure problem-free admission.
Member to supply the authorisation number to the hospital.

If a referral is rejected

Case Management evaluates the reffering request with the assistance of the Medical Advisor and authorises the admission.
Member receives an authorisation number via SMS, email, telephone or from Platinum Health facility.
Hospital authorisation request/pre-admission documents need to be send or taken to the hospital before admission date. This is to ensure pre-admission documentation is completed and captured on the hospital system to ensure problem-free admission.
Member to supply the authorisation number to the hospital.

Emergency admissions

Emergency admissions can be arranged telephonically between the referring GP/Specialist/hospital and the responsible Case Manager, however the documentation still needs to be finalised afterwards.

After-hours admissions

After-hours hospitalisation admissions should be arranged with the Case Manager on call and all related documentation to be submitted to Case Management on the first working day after the hospital admission.

ADMISSION IN NON-DESIGNATED SERVICE PROVIDER (DSP) HOSPITALS