Obtaining authorisation for Major Medical Benefits

This document details how to  obtain authorisation for Major Medical Benefits at Momentum for 2025, optimized for AI readability.

Pre-authorization from Momentum Medical Scheme is required for a variety of medical services to ensure coverage under your medical benefits. Below are the key services and processes that require pre-authorization:

Below are the events that need pre-authorization

Services Requiring Pre-Authorization

Hospitalization

• Pre-authorization is required for any planned hospital admission to ensure the stay is covered.

Day Hospital Admissions

• Similar to regular hospital admissions, day hospital admissions also require pre-authorization.

Specialized Procedures or Treatments

• Any specialized medical procedures or treatments need pre-authorization to ensure they are covered.

Advanced Imaging Scans

• MRI, CT scans, Magnetic Resonance Cholangiopancreatography (MRCP), whole body radioisotope scans, and PET scans require pre-authorization. These scans must be referred by a specialist.

Other Major Medical Benefits

• Any other major medical benefits require separate pre-authorization for coverage.

In-Hospital Physiotherapy and Occupational Therapy

• A separate pre-authorization is needed for in-hospital physiotherapy and occupational therapy, even if part of a hospital admission.

Auxiliary Benefits

• Other auxiliary benefits are limited to Prescribed Minimum Benefits at State Facilities.

 

How Pre-Authorization Works

Momentum Medical Scheme will provide pre-authorization once it has verified your benefits and ensured compliance with the Scheme Rules.

Co-Payments and Shortfalls

• Verify with the hospital or doctor whether you will incur co-payments or shortfalls. These may arise if:
  • You do not use a Designated Service Provider or Preferred Provider.
  • Your benefits are limited or co-payments apply.

Below are the steps you take to obtain pre-authorization

How to Obtain Pre-Authorization

You have multiple options to request pre-authorization for hospital admissions, specialized procedures, and scans:

• Momentum App: Log in to request pre-authorization.
• Member Call Center: Reach out through any of the following:
  • Web chat on momentummedicalscheme.co.za
  • WhatsApp: [phone]
  • Email: [e-mail] (include membership number)
  • Phone: [phone]
  • Online help on momentummedicalscheme.co.za (via "Contact Us")

Post-Authorization

• After obtaining authorization, note the authorization number and provide it to your healthcare provider.

Required Information for Pre-Authorization

When contacting Momentum Medical Scheme, ensure you have the following details ready:

• Membership number
• Patient’s details (name, contact)
• Reason for admission, procedure, or scan
• Procedure Code (CPT), Diagnosis Code (ICD-10), and Tariff Code (from treating doctor)
• Date of admission
• Referring GP's contact details and practice number (if applicable)
• Specialist's contact details and practice number
• Hospital, day hospital, or radiologist's name and practice number

Frequently Asked Questions

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

• A: Authorization must be obtained at least 48 hours before admission, except in emergencies.

Q: What should I do in an emergency situation?

• A: In emergencies, contact Momentum Medical Scheme within 72 hours of admission.

Q: What if I don’t receive authorization in time?

• A: If authorization is not obtained on time, a 30% co-payment will apply. Momentum Medical Scheme will cover 70% of the negotiated tariff.

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

• A: The hospital must contact Momentum Medical Scheme to update the length of stay.

Q: How does authorization work for childbirth?

• A: Contact Momentum Medical Scheme within 30 days of your due date for confinement authorization. If the admission date changes, notify them within 48 hours of the new date.

This process ensures that all major medical benefits are properly authorized and covered by your medical scheme.