Illustration: Colin Daniel
Illustration: Colin Daniel

Get your PMB claims paid

By Laura du Preez Time of article published Apr 10, 2011

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Your medical scheme may identify and pay your prescribed minimum benefit (PMB) claim automatically based on the diagnostic code on your claim, but some schemes say they cannot always identify a claim as a PMB from this code. Therefore, you must be aware which claims are covered by the PMBs and should be paid by your medical scheme.

If you know which claims are PMBs, you will be in a position to question why your scheme rejected a claim that you believe it should have paid or why the claim was paid from your medical savings account when it should have been paid by your scheme.

You should also know when a scheme requires you to apply for authorisation for a PMB, because failing to do so will result in your claim being treated as a non-PMB claim, which may result in it being rejected, your having to pay a co-payment or the claim being paid from your medical savings account.

An incorrect diagnostic, or ICD-10, code could also result in your claim being rejected.

Most medical schemes will identify and pay hospital admission PMB claims automatically.

But, if you have one of the 27 common chronic conditions, many but not all schemes require that you register with them for these to qualify as PMB claims, questions Personal Finance put to six large schemes revealed. The registration may be annual or required with each change in medication.

Schemes have different policies for other PMB claims, which cover once-off acute out-of-hospital PMB claims, such as acute otitis media (middle ear infection), and out-of-hospital PMB conditions that involve ongoing chronic medication.

Other PMBs that require chronic medication include post-transplant medication, hormone replacement therapy, medication for metabolic and endocrine conditions (such as hyperthyroidism), anti-coagulative therapy, medication after cardiac surgery, and medication required by quadriplegics and people with valvular heart disease.

Dr Jonathan Broomberg, the chief executive officer of Discovery Health, says the PMB code of conduct acknowledges that ICD-10 codes alone are not accurate enough to confirm a positive diagnosis for a PMB condition. (The code was drawn up by the medical schemes industry and the Council for Medical Schemes in July last year.)

Discovery Health requires its members to supply further information, by completing an application form, for any PMB that involves chronic medication.

If you are successfully registered for chronic medication for one of the 27 common chronic conditions, all further claims for that condition will be paid automatically.

Anton Rijnen, the chief executive officer of Medihelp, says Medihelp expects doctors to complete an application form for PMBs that require medication. For all other PMBs, doctors are expected to apply for authorisation telephonically with Medihelp’s PMB pre-authorisation division.

Bonitas Medical Fund, Fedhealth Medical Scheme, Medshield Medical Scheme and Momentum Health Medical Scheme all say they use the ICD-10 codes to identify PMB claims.

However, both Momentum and Fedhealth require their members to obtain authorisation for treatment for all or some of the common chronic conditions.

Broomberg says the code of conduct clearly differentiates between PMB claims that have a chronic and predictable component (and which therefore lend themselves to an initial registration, followed by the automatic payment of claims with the relevant ICD-10 code thereafter) and claims that are more acute and non-recurring in nature, and for which a specific application for PMB cover on each occasion is therefore appropriate.

While Discovery, like most schemes, does not expect you to apply for PMBs treated in hospital, there may be cases where the scheme will not pick up that the claim was for an in-hospital PMB and then you will have to apply for cover for that claim retrospectively, Broomberg says.

Most scheme options that offer private hospital cover will pay your hospital bills anyway, but the costs of treatment by a specialist while you are in hospital may not be covered in full.

Usually, some kind of application for cover is required for acute once-off out-of-hospital non-emergency PMBs, such as middle ear infection. This is because the information that the scheme receives on your claim is insufficient to identify the claim as a PMB, Broomberg says.

In the case of out-of-hospital PMBs that involve chronic medication, Discovery requires once-off registration to confirm the diagnosis, he says.

For example, Broomberg says, a practitioner could use the ICD-10 code for hyperthyroidism to indicate that someone has been tested for the condition, but the test may prove negative and then it will not be covered as a PMB.

Many schemes, including Discovery Health, Bonitas, Medshield and Fedhealth, have a standard set of benefits for out-of-hospital PMBs that require chronic medication. This is especially true of the common chronic conditions, because medical schemes are obliged to provide benefits as laid down in treatment algorithms published with the PMB regulations. This standard set of benefits, or defined basket of care, will include the associated blood tests, consultations and treatments required to manage your condition, Broomberg says.

Once you have obtained authorisation to treat your condition, Discovery Health, like a number of other schemes, automatically identifies and pays for all treatments that fall within the relevant defined basket of care, he says.

Second-tier treatment falls outside the standard basket of care, Broomberg says. You are entitled to this care if you need it, but your doctor may have to provide clinical motivation before you can claim for it as a PMB and this can also involve an application process, he says.

The problem is that if you or your doctor are not aware that you need to apply for approval for second-tier treatment, you may find that your PMB claims are rejected. If you become aware of the need to seek approval after you have begun treatment, ask your scheme to approve the claims that you have already incurred.

Lee-Ann du Toit, the chief marketing officer of Momentum Health, says that when members register for cover for one of the 27 chronic PMB conditions, a treatment plan is drawn up on request.

Du Toit says that while Momentum Health’s systems recognise the diagnostic codes for PMBs, in some cases healthcare providers use default unspecified codes, also known as Z codes, for yet-to-be-diagnosed conditions. Examples are certain radiology and pathology tests, where the use of a descriptive coding is not a requirement, she says.

In this case, Momentum will regard the claim as a non-PMB one. Once your diagnostic tests confirm your condition as a PMB, you need to provide the scheme’s administrator with the relevant information and ask it to pay the claim as a PMB.

Du Toit says that in some cases the scheme may request further information or a motivation from the doctor regarding treatment.

In the case of a high-cost prosthesis (such as a pacemaker), Momentum Health will obtain the quote upfront and try to negotiate with the supplier for a better price.

Gerhard van Emmenis, Bonitas’s acting principal officer, says Bonitas members are not expected to apply for PMB cover for the common chronic conditions. Bonitas can identify these conditions from the ICD-10 codes and this entitles members to a set of standard benefits. If members require benefits beyond these standard benefits, they need to submit a motivation, he says.

Duduza Khosana, the executive principal officer of Medshield, says that Medshield also does not require an application form for the standard treatment for the 27 common chronic conditions, because it identifies these from the ICD-10 codes, the chargeable or service code and the medical speciality that treats that condition.

Care above standard treatment requires the submission of a motivation, and Medshield has a manual process for all other PMB claims.

Khosana also notes that in most cases, pathology and radiology claims are not submitted with the correct ICD-10 codes and therefore are not identified as PMBs. The healthcare provider has to correct the claim and resubmit it, she says.


Medical schemes pay your prescribed minimum benefit (PMB) claims based on a diagnostic code, so you need to know what the code is for your PMB condition and ensure that it is on every claim related to your condition.

Ask the doctor who treats you to help you.

When you are sent for tests or scans or any other treatment, try to ensure that the relevant form for the test, scan or treatment is completed by the doctor who treats you and that he or she inserts the correct codes.

If you have to fill in a PMB application form, try to ensure that you include all related tests, medicines and consultations, as well as their relevant diagnostic codes and the service or chargeable codes.

Your doctor may also have to help you complete the PMB application form, and he or she may charge you for the time it takes to fill in the form.

Dr Jonathan Broomberg, the chief executive officer of Discovery Health, says doctors are the only people who are equipped to make the formal diagnosis that is essential for medical schemes to manage their PMB cover risks appropriately. Doctors are also the appropriate people to motivate for treatments outside the basket of care, or first tier of treatment, Broomberg says.


Two recent cases highlight how medical schemes can get your prescribed minimum benefit (PMB) claims wrong and why you need to be aware of your rights and to enforce them when your scheme does not.

Member with hyperthyroidism

A woman with hyperthyroidism, which is a PMB, had her claims for the illness paid from her medical savings account for almost three years before she realised that her medical scheme should cover the treatment in full.

The woman was diagnosed with Graves Disease, a form of hyperthyroidism, or overactive thyroid, in late 2006.

She checked the PMBs for her condition, but only hypothyroidism (an underactive thyroid) is listed as a common chronic condition.

Among the 270 PMB treatment pairs, “hyper- and hypo-thyroidism with life-threatening complications or requiring surgery” is listed but not Graves Disease.

The woman wrongly assumed that her condition was not as serious as suggested and therefore not covered.

Throughout 2007, and when the condition resurfaced in 2009, Oxygen Medical Scheme paid claims related to the condition, which amounted to more than R13 000, from the member’s savings account. Once the funds in her account were exhausted, the woman paid for the treatment herself.

Last year, the woman moved to Discovery Health Medical Scheme. In the same year, she required radioactive iodine treatment at a cost of about R6 000. The treating doctor suggested that the woman insist that the scheme pay for the treatment, because the condition is a PMB.

The woman established from the Council for Medical Schemes that Graves Disease is indeed a PMB and that all previous claims related to the condition should have been paid by her scheme and not from her medical savings account.

The woman asked Discovery Health to reconsider her claims as a PMB. She was sent and completed a PMB chronic disease application form.

A month later, she was informed that the application was successful and that the scheme would cover the medication and consultations for the condition from then on.

However, the claim for radioactive iodine treatment was still not paid, apparently because the hospital codes for this treatment were not included on the form and treatment was approved only from the date of application.

The woman says that none of these requirements was explained when she was sent the PMB application form. Her doctor was also unaware of them, despite the fact that he is a specialist who has agreed to charge Discovery Health rates.

The woman re-submitted the PMB application form with all the relevant codes and dates to the scheme.

More than two months later, after numerous calls to the call centre and the intervention of a medical scheme broker, the claim for the radioactive iodine was finally paid.

The claims paid from the member’s savings account have yet to be reversed, but Discovery says it is working on this.

In addition, claims from this year have again been paid from the woman’s savings account. On inquiring, the call centre told the woman that she needed to complete a new PMB application form for 2011.

Dr Jonathan Broomberg, the chief executive of Discovery Health, says remedial action was taken to address this case and the medical scheme found that hyperthyroidism was not registered in its systems correctly.

For this reason, the member’s claims for at least the first level of care (medication, consultations and blood tests) were not paid automatically as they should have been.

The case was not handled in line with Discovery’s usually high standards, Broomberg says.

Discovery processes 1 500 new chronic medication applications each working day and most are handled efficiently, he says. Some errors are made despite efforts to minimise them.

Member with multiple sclerosis

The Council for Medical Schemes last year ruled that LA Health had to pay the physiotherapy claims of a member with multiple sclerosis.

The scheme had been paying the man’s physiotherapy claims from his medical savings account. When the member complained, LA Health told him that physiotherapy was not included in the PMB basket of care for multiple sclerosis.

LA Health said the regulations under the Medical Schemes Act contain an algorithm that deals with the minimum treatment that schemes have to provide for the PMBs that refers to “supportive care”, but this is not elucidated.

The Medical Schemes Act states that schemes have to provide PMBs in line with the prevailing treatment in state healthcare facilities, but, according to LA Health, physiotherapy was not provided to state patients with multiple sclerosis.

Investigations by the Council for Medical Schemes found that Steve Biko Hospital in Pretoria provided physiotherapy, including hydrotherapy, to state patients with multiple sclerosis.

The Registrar of Medical Schemes therefore ruled that LA Health had to pay this member’s claims for physiotherapy in full.

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