Before you go to hospital for any planned procedure, you must:
- See your doctor who will decide if it is necessary for you to be admitted
- Make sure you know how the account from your admitting doctor will be covered
- Choose which hospital you want to be admitted to
- Find out how we cover other Healthcare Professionals, for example your anaesthetist
- Your TFG Medical Aid Scheme membership number
- When you'll be admitted to hospital and how long you'll stay
- Your treating doctor's name and practice number
- The name and practice number of the hospital or day clinic
- The date of procedure
- Your diagnosis (ask your doctor for the ICD-10 diagnosis code)
The procedure name and code, if available (ask your doctor for the RPL procedure codes)
N.B. On TFG Health, if you are not admitted via casualty, your chosen GP must be both your admitting and treating doctor.
You must preauthorise at least 48 hours before your planned hospital admission, except in emergencies.
On TFG Health a 30% non-notification penalty fee will apply, if the member does not preauthorize their admission. Therefore, 70% of the hospital and related accounts will be covered and you will be responsible to pay the difference.
On TFG Health Plus a co-payment of R2 000 will be levied on the hospital account if preauthorisation is not obtained, except in an emergency.
In certain instances you will not have to pay co-payments or deductibles
The Scheme will still pay the Prescribed Minimum Benefit claims in full if you have involuntarily obtained the services from a provider other than a Designated Service Provider, if:
- it was an emergency, for hospital admissions
- the service was not available from the Designated Service Provider or would not have been provided without unreasonable delay; or
- there was no Designated Service Provider within a reasonable distance from your place of business or residence.
The Scheme's designated service providers for the diagnosis, treatment and care costs (which may include medicine) for Prescribed Minimum Benefit (PMB) conditions are:
TFG Health
TFG Health members are serviced by KeyCare network providers only. These networks are as follows:
- KeyCare Network Hospitals (PMB Network Hospital) and Casualty units, with the addition of home-based care in private facilities as Designated Service Providers (DSP)
- KeyCare Network GP
- KeyCare Health DPA Specialist
- Premier Plus GP
- Independent Clinical Oncology Network (ICON)
- A defined list of pharmacies the Scheme has contracted with known as DSP
- Dental Network (Dental Risk Company/DRC)
- KeyCare Network optometrists (IsoLeso)
- A defined list of Radiologists, Radiographers, Psychologists and Social Workers with whom the Scheme has entered into a Preferred Provider agreement with
- An out-of-hospital Mobility Network and Renal Network the Scheme has entered into a Preferred Provider agreement with
- Day-surgery Network
- A defined list of oncology pharmacies to obtain medicine related to oncology treatment
The above Networks are defined in the main body of the Scheme Rules and the voluntarily use of services outside of the TFG Health Benefit Plan's contracted network providers and facilities, will attract deductibles or co-payments. The basis of cover for PMB conditions and circumstances within which the Scheme will make payment in full on this benefit plan is set out in Annexure B4 of the Scheme Rules.
TFG Health Plus
TFG Health Plus members may make use of any hospital facility, however to ensure members do not experience deductibles in the case of PMB conditions, the following Network and Designated Service Providers (DSP) are in place to service members:
- KeyCare Network Hospitals (PMB Network Hospital), with the addition of home-based care in private facilities as Designated Service Providers (DSP)
- KeyCare Network GP
- A list of Specialists contracted as Designated Service Providers (Classic Direct Payment Arrangements)
- Premier Plus GP
- A defined list of pharmacies the Scheme has contracted with known as DSP
- A defined list of Phycologists, Social workers and Midwifes with whom the Scheme has entered into a Preferred Provider agreements with
- An out-of-hospital Mobility Network the Scheme has entered into a Preferred Provider agreement with
- Day-surgery Network
- A defined list of oncology pharmacies to obtain medicine related to oncology treatment
The above Networks are defined in the main body of the Scheme Rules and the voluntarily use of services outside of the TFG Health Plus Plan's contracted network providers and facilities, may attract deductibles or co-payments. The basis of cover for Prescribed Minimum Benefit (PMB) conditions and circumstances within which the Scheme will make payment in full on this benefit plan is set out in Annexure C2 of the Scheme Rules.
It is important to note that where the Scheme has appointed a Designated Service Provider (such as these listed above), non PMB's will only be paid in full if the services are obtained at the DSP.