Hospital admissions and emergencies

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:

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.