Obtaining authorisation for Major Medical Benefits

Below is information about obtaining authorization for Major Medical Benefits

It is essential to obtain pre-authorization from Momentum Medical Scheme for the following services:

• Hospitalization: This includes any overnight stay in a hospital for treatment.
• Day hospital admissions: This refers to procedures that require a patient to be admitted for a day but do not necessitate an overnight stay.
• Specialized procedures or treatments: These are specific medical interventions that require special expertise or facilities.
• Advanced imaging services: This includes MRI, CT scans, Magnetic Resonance Cholangiopancreatography (MRCP), whole-body radioisotope scans, and PET scans. It is important to note that a referral from a specialist is required for these services.
• All other Major Medical Benefits: Any other medical services that fall under major medical care must also be pre-authorized.

In addition, it is necessary to obtain a separate pre-authorization from Momentum Medical Scheme for any in-hospital physiotherapy and occupational therapy, even if these services are part of a hospital admission. Other auxiliary benefits are limited to Prescribed Minimum Benefits when accessed at State Facilities.

Pre-authorization will be granted once your benefits have been verified and the Scheme Rules and protocols have been applied. If the hospital or your doctor secures the authorization on your behalf, it is crucial for you to verify whether you will incur any co-payments or shortfalls. These may arise from not utilizing a Designated Service Provider or Preferred Provider, or due to any benefit limits and applicable co-payments.

How to obtain pre-authorization

To obtain pre-authorization for hospital admissions, specialized procedures, treatments, and specialized scans, you can conveniently log into the Momentum App. Alternatively, you can reach out to our member call center for assistance with pre-authorization for these services and any other Major Medical Benefits. Here are the ways you can contact us:

• WhatsApp us at [phone];
• Visit momentummedicalscheme.co.za and click on the help button to access our web chat facility;
• Email us at [e-mail];
• Call us directly at 0860 11 78 59.

Don’t forget to take note of the authorization number provided to you, as it is essential to share this number with your healthcare provider(s).

When you reach out to us, please ensure you have the following information readily available:

1. Your membership number.
2. The name and details of the patient.
3. The reason for the hospital or day hospital admission, procedure, treatment, or specialized scan.
4. The procedure code (CPT), diagnosis code (ICD-10), and tariff code. These details must be obtained from your treating doctor.
5. The date of admission.
6. The contact details and practice number of the referring GP, if applicable.
7. The contact details and practice number of the specialist.
8. The name and practice number of the hospital, day hospital, or radiologist.

Frequently asked questions

Q: Can an authorization number be issued on the day of admission?

A: Authorization must be secured at least 48 hours prior to admission, except in cases of emergency admissions.

Q: What happens if it is an emergency situation?

A: In the event of an emergency, you, a family member, or a friend must contact us within 72 hours of the admission.

Q: What if I do not get authorization in time?

A: If authorization is not obtained in time, a co-payment of 30% will apply to all claims related to the event. Momentum Medical Scheme will cover 70% of the negotiated tariff, assuming that authorization would have been granted according to the Scheme's Rules.

Q: What if the length of stay needs to be extended beyond the authorized period?

A: In such cases, the hospital must reach out to us to update the length of stay.

Q: How does authorization work for childbirth?

A: For childbirth, please contact us within 30 days of your due date to request authorization for your confinement. If there are any changes to your admission date, you have 48 hours from the new admission date to notify us.