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MEMBERGUIDE
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KEYHEALTH MEDICAL SCHEME
GLOSSARY
BENEFIT OPTIONS
MEMBERSHIP
TERMINATION OF MEMBERSHIP
CONTINUED MEMBERSHIP
MEMBERSHIP FEES
PRESCRIBED MINIMUM BENEFITS
PRESCRIBED ACUTE MEDICATION
To take out medication (TTO)
SELF MEDICATION
PRESCRIBED CHRONIC MEDICATION (Life-sustaining Medication)
REFERENCE PRICING
MAXIMUM MEDICAL AID PRICE (MMAP®)
MANAGED HEALTH CARE
PRE-AUTHORISATION OF HOSPITAL ADMISSIONS
CASE MANAGEMENT
PREGNANCY MANAGEMENT PROGRAMME
ONCOLOGY MANAGEMENT PROGRAMME
ORGAN TRANSPLANTS AND DIALYSIS
DISEASE MANAGEMENT
DIABETES
HIV MANAGEMENT PROGRAMME
DENTAL BENEFIT MANAGEMENT
MEDICAL APPLIANCES
HEARING AIDS AND MAINTENANCE
INTERNAL AND EXTERNAL PROSTHESIS
OPTICAL BENEFITS
EMERGENCY TRANSPORT: Netcare 911 (082 911)
CLAIMS PROCEDURE
SAVINGS ACCOUNT
GAP-COVER
FOREIGN CLAIMS
MOTOR VEHICLE ACCIDENTS
INJURY ON DUTY
LIST OF EXCLUSIONS
FRAUD LINE
THE INTERNET www.keyhealthmedical.co.za
E-MAIL FACILITY
SMS FACILITY
YOUR CLAIMS ADVICE
IMPORTANT CONTACT INFORMATION
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MEMBERGUIDE 2008
1.
KEYHEALTH MEDICAL SCHEME
Why KeyHealth?
KeyHealth was formed in 2007 by the amalgamation of Global Health and Munimed
Medical Schemes. Both schemes have much in common. They originated in the sixties
(Munimed in 1966 and Global in 1969); they began as closed schemes providing cover
to employees of local authorities (Munimed in the then Transvaal and Global in Natal);
they merged with other existing local government schemes (Munimed with the Free State
Scheme and Global with Pretmed); and both became open schemes (Global in 1992 and
Munimed in 2000).
Rules
It is imperative for you to have a clear understanding of the scheme rules to avoid any
possible misconception in future.
Please note: This guide is only a summary of the scheme rules. A copy of the official rules
is available on request. In the event of a dispute, the official rules as registered with the
Council for Medical Schemes, will apply.
Limitation of expenditure
The sensible use of medical services will restrict your scheme’s expenditure and thus limit
your own membership fees.
2.
GLOSSARY
Agreed tariff: A tariff agreed upon from time to time between the Scheme and service
providers eg. hospital groups.
Angiograms: X-rays of the arteries using special colouring of the blood
Audiology: Measurement of hearing and correction of hearing problems
Automatic Authorisation List (AAL): A list of chronic medication that has been approved
by KeyHealth
Chiropractor: A practitioner who treats mainly the spine.
Chronic Disease List (CDL): A list of chronic illnesses that are covered in terms of
legislation.
Chronic Medicine: Medication used on an ongoing basis for conditions listed in the
Automatic Authorisation List (AAL).
Clinical management: The rules that apply to treating specific conditions as well as
medical procedures.
Conservative dentistry: Simple dental services, such as fillings, extractions and teeth
cleaning (oral hygiene).
CT and MRI Scans: Special X-rays taken of the inside of the body to try to find the cause
of an illness.
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Day-to-day benefit: A combined out of hospital limit which may be used by any member
of the family, in respect of GP’s and Specialists, radiology and pathology, prescribed
medicine and auxiliary services, which also includes a sub limit for self medication.
Dental Benefit Management Programme: A cost and quality dental management
programme managed by DENIS
Designated Service Provider (DSP): Provider of medical services with whom special
rates were negotiated.
Generic: A medicine that has the same ingredients as, and works exactly as a well known
brand medicine, usually at a cheaper cost.
Homeopathy: A complementary disease treatment system in which a patient is given
natural drugs.
MMAP: MMAP® A programme through which the maximum price your scheme is prepared
to pay, for specific categories of generic medication.
Medical Scheme Tariff (MST): Also referred to as Keyhealth tariff. A tariff the scheme
pays for services rendered by a service provider. Should the tariff charged by the service
provider exceed the MST, the member will be liable for the difference.
National Reference Price List (NRPL): Recommended medical tariff published by the
Council for Medical Schemes.
Oncology: The treatment of cancer
Optical Management: A cost and quality management programme managed by
Opticlear.
Prescribed Minimum Benefits (PMB): Prescribed minimum benefits cover you for
specific treatments and services rendered in a state facility.
SwiftAuth OnLine™ : Authorisation needed for certain chronic medicine not included in
the AAL.
3.
BENEFIT OPTIONS
KeyHealth offers five excellent benefit options from which members can choose, depending
on individual needs and financial position.
Platinum: This option provides comprehensive cover for high expenditure of chronic
medicine and day-to-day benefits.
Gold: This option provides good comprehensive cover for families with a day-to-day
benefit.
Silver: This option provides adequate cover for day-to-day expenses with limited chronic
benefits.
Bronze: This option provides cover for the young and healthy, with limited day-to-day
benefits.
Keycap: This option provides affordable cover at Private hospitals and your chosen
network provider.
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MEMBERGUIDE 2008
For more details on your medical benefits, consult your benefit brochure or contact the
Client Service Centre on 0860 671 050.
Benefit option on application
Prospective members should clearly indicate on the application forms which benefit option
they choose.
Summary of benefits
The benefits and membership fees payable in terms of the rules of the Scheme are
summarised in a benefit brochure.
Exchange of benefits prohibited
Legislation prohibits the exchange of benefits between service categories e.g chronic
medication benefits still available to the member, cannot be used towards the payment of
acute medicine claims.
4.
MEMBERSHIP
Who qualifies
KeyHealth is an open scheme and membership is available for private individuals and/or
employer groups.
Legislation prohibits a person from belonging to more than one scheme at a time.
Who qualifies to register as a dependant
The following members of a family will qualify, if they are not members or dependants of
any other medical scheme:
• Your spouse to whom you are married in terms of any law or custom;
• Your life partner with whom you have a serious relationship similar to a marriage
and based on objective criteria such as mutual dependence and a shared and joint
household, irrespective of the sex of the parties;
• Your own, step- or legally adopted children under the age of 21 who are dependent on
you,
• Your child who is under the age of 25 and a full-time student at an educational
institution,
• Your child who is dependant on you because of mental or physical disability or any
similar cause;
• Your child who is under the age of 21 years and who does not receive a regular
income more than the Social Pension;
• Your unemployed child who is over the age of 21 and totally dependant on you.
Students and children older than 21 years
Children above the age of 21 years are regarded as adult dependants, unless they are
studying full-time at a recognised secondary or educational institution. A member should
submit annual proof of registration for his/her dependants who are above the age of 21
years, but who are still studying full-time at an educational institution. He/she will still be
MEMBERGUIDE 2008
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regarded as a child dependant. A student over the age of 25 years will be regarded as an
adult dependant.
A dependant child membership will change to adult dependant membership at the
beginning of the month following the dependant’s 21st birthday, if he/she is not a full-time
student at a recognised secondary or educational institution.
Please note: Proof of registration should be submitted at the beginning of each academic
year. If not, the dependant will automatically be regarded as an adult dependant and
premiums will be charged accordingly.
Please note: Proof of dependence will have to be submitted for a child over the age of 21
years and for other members of your family.
Application for inclusion of dependant(s)
A member must complete the application form “Additional Dependant(s)” and send it to
KeyHealth’s New Business division or fax to (012) 673 2800.
Special dependants
Any other member of your immediate family (i.e. your parents, brothers, sisters) with
regard to whom you are responsible to provide financial support for, will be regarded as
special dependants. A sworn statement indicating the special dependant’s dependency on
your financial care should accompany the application.
Newborn and adopted children
The registration of newborn and adopted children should take place within 30 days after
the birth of a child or the date on which the child is legally adopted. The application must
be accompanied by a birth certificate and/or proof of adoption.
If an application is not received within the abovementioned time, KeyHealth shall have the
right to make the initial date of the dependant’s membership subject to a general waiting
period of three months and/or to impose a waiting period of 12 months on existing illnesses
for these dependants.
What happens when your particulars change?
Inform KeyHealth in writing within 30 days and send the letter to:
Attention: Member Administration
KeyHealth
P.O. Box 14145
Lyttelton
0140
or fax to: (012) 673 2800
These changes can also be made on the website at www.Keyhealthmedical.co.za
Let the Scheme know of the following changes:
• Registration of new dependants
• Dependants who no longer qualify for membership
• Address
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MEMBERGUIDE 2008
• Bank details
• Income
The Scheme should be notified of any changes within 30 days. No changes will be
implemented retrospectively.
Please remember to state your name, surname and membership number on your letter
and ensure that certified copies of birth, adoption, marriage or death certificates, sworn
statements in the case of life partners, are included. A copy of this letter should also be
sent to your employer if you receive a subsidy.
Please call KeyHealth’s Client Services to find out how your membership fees and benefits
will be affected by any changes in your membership status.
Insurability
The Scheme has the right to request a health certificate for any applicant and his/her
dependants. Proof of health is provided by a member when he/she completes the health
questionnaire on the application form and signs the statement of health.
Please note: It is important to list all operations and illnesses. This will prevent claims
from being rejected because of waiting periods and/or exclusions during the first year of
membership.
Consequences:
• If a member or dependant suffers from a specific illness, KeyHealth has the right to
exclude the member and/or dependant from benefits for this specific condition for a
period of 12 months.
• Should it be found that a member submitted false information or has deliberately left
out any relevant information during his/her application, the Scheme may correct this in
terms of its rules or terminate the member’s membership.
How soon can you claim after you have joined the scheme?
From the date of entry, but please note that certain services may be subject to exclusions
or a waiting period.
A general waiting period of 3 months will usually be applicable if:
• You were not previously a member of a registered medical scheme
• You were a member of a registered medical scheme for more than two years and the
change of medical scheme was not as a result of conditions of employment
• The period between the termination of membership from your previous scheme and
you joining KeyHealth exceeds ninety days.
A 12-month waiting period for pre-existing illnesses, will usually be applicable if:
• You did not previously belong to a medical scheme,
• You were a member of a registered medical scheme for less than two years and the
change of medical scheme was not as a result of conditions of employment
• The period between the termination of membership from your previous scheme and
you joining KeyHealth exceeds ninety days.
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If you are still serving a waiting period at another scheme, the remainder thereof can be
transferred to KeyHealth.
What happens if you should become a member during the course of the year?
If you join KeyHealth during the course of the benefit year (1 January to 31 December),
you will receive pro rata benefits. This means that your annual maximum on benefits will
be reduced according to the number of months left in the benefit year.
If, for example, you become a member halfway through the year (i.e. with a remaining 6
months) and the annual maximum for a certain service is usually R1 000, you will only be
able to claim half of this, i.e. R500.
Proof of membership
Every main member who has dependants is provided with 2 membership cards as proof
of membership. Members without dependants are supplied with 1 membership card.
Your membership card is proof to the service provider that you and your dependant/s
are registered KeyHealth members. This card must be shown on request of the service
provider, eg. a medical practitioner. In the event of any enquiries in this regard, the Client
Services Centre can be contacted at 0860 671 050.
Information on the card
The following information appears on the membership card and must be checked by the
member for accuracy and completeness:
• registration date;
• benefit date;
• names of main member and all dependants;
• the identity number of all members; as well as
• the gender of dependants.
Ownership
This card remains the property of the scheme and must be returned to KeyHealth when
membership is terminated.
Change of benefit options
A member is entitled to change his option, subject to the following conditions:
• The change may only be effective as from 1 January.
• An application to change benefit options must be made in writing and must be
submitted to KeyHealth by 31 December of the year, before the change takes effect.
• Within 3 months after joining, a new member must exercise his final choice of benefit
options in writing, and this will be effective from the date of joining with the
correction of membership fees accordingly. If a member does not inform the Scheme
in writing of his final choice before/or on the last day on which the period of 3 months
expires, the member is automatically placed on his initial choice, after which a further
choice between options can only be exercised as from 1 January of each year, subject
to the abovementioned stipulations.
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MEMBERGUIDE 2008
Retirement
It is the member’s responsibility to ensure that KeyHealth is notified in writing about his/her
retirement and whether he/she will continue membership as a member. This notification
should be done at least three months prior to the retirement date. KeyHealth will inform
the member on the conditions for continued membership. Members who are subsidised
by employers need to confirm with their employers whether the subsidy will continue after
retirement. If not, the member will be responsible for the full membership fee. Members
who retire may change options.
5.
TERMINATION OF MEMBERSHIP
When will your membership be terminated?
• If you resign from your employer (where membership was a condition of service and
you do not intend to retain your membership);
• On your death;
• When KeyHealth receives one months’ notice of cancellation from you;
• When KeyHealth receives one months’ notice of cancellation from your employer;
• Membership may also be terminated if KeyHealth should find that a member and his/
her dependants have misused the benefits of the Scheme. The member may then
have to repay any amount which the scheme has paid on his/her behalf;
• When you are no longer a member in terms of any other stipulations of the Scheme.
How do you resign as a member?
A member should give written notice one month in advance stating the reason for the
resignation, as well as the date of resignation.
Dependant
A dependant will no longer be a dependant if:
• The main member’s membership is terminated;
• The member notifies the scheme to terminate membership of a dependant;
• A dependant no longer qualifies as a dependant (as stipulated by the rules of the scheme).
6.
CONTINUED MEMBERSHIP
Upon retirement
When you retire, you will be entitled to remain a member of the Scheme, subject to the
rules of the scheme.
Upon the death of the main member
If the membership of a member terminates as a result of his/her death, the benefits in
respect of such a member’s dependants may be continued in terms of the rules of the
Scheme, provided that:
• The remaining spouse/partner is registered as the new main member;
• If there is no spouse/partner, the oldest dependant is registered as the new main member;
MEMBERGUIDE 2008
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• If the membership fees are adjusted, depending on the number of remaining
dependants and is calculated according to the income of the widower/widow/partner
or, if there is no spouse/partner, according to the income of the oldest dependant; and
• If the adjusted membership fees are paid to KeyHealth without interruption.
Please note: It is the new main member’s responsibility to inform KeyHealth regarding
his/her continued membership. This should take place within three months of the death of
the original main member. KeyHealth will inform the new main member on the conditions
of continued membership.
7.
MEMBERSHIP FEES
Calculation
Membership fees are calculated according to the income scale of the main member, the
number of children and/or adult dependants and the benefit option.
Premium loading for persons who join a medical scheme late in life
A premium loading may be imposed on persons (a member or adult dependant) older than
35 who was not a member or dependant of a medical scheme from a date before 1 April
2001. This loading is calculated according to the years spent without cover after the age
of 35, with credit given for years of cover after the age of 21, according to the following
scales:
1-4
years at 5%
5-14 years at 25%
15-24 years at 50%
25+
years at 75%
Payment of membership fees
The membership fees of employer groups and Persal, which has a concession according
to which membership fees are levied retrospectively, are payable before or on the last day
of the month.
Example: The membership fees for January are received on 31 January.
The fees of all members not included in the abovementioned concession are payable in
advance and should reach the scheme before the 7th of each month.
Example: The membership fees for January are payable by 7 January.
Recognition of rules
The payment of membership fees is regarded as the member’s recognition that he/she is
bound by these rules and any amendments made thereto with regard to him/her and his/
her dependants.
Change of membership fees
If the membership fees should be adjusted due to an additional dependant, the adjusted
membership fee must be paid on the first day of the month following the dependant’s
registration date.
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MEMBERGUIDE 2008
Please note: Benefits for such a dependant will apply from the date on which he/she has
become a dependant, provided that all conditions have been met.
What happens if your income should change during the year?
KeyHealth contributions are amongst other things based on your income, and therefore
any change in your income will affect this contribution.
You should inform the scheme of any increase (or decrease) in your income. Proof of
income will have to be submitted in the form of the latest payment advice from your
employer if you are a full-time employee, or alternatively in the form of a sworn statement
with written proof.
The scheme reserves the right to request proof of income at any time.
What will happen if you do not provide proof of income?
Unless satisfactory proof of income is provided, your membership fees will fall into the
highest income category, as indicated on the membership table.
Payment of fees
Contribution payments can be made into the following bank account:
Bank: ABSA LYTTELTON
Name of account holder: KeyHealth
Account Number: 600000012
PLEASE do not mail cash or cheques
Members are requested not to send cash or cheques to KeyHealth by mail. Envelopes get
tampered with in the mail and quite often damaged during sorting in the postal system.
KeyHealth does not accept responsibility if cash or cheques get lost in the mail.
Please remember to use your membership number as a reference for all deposits and
fax the proof of payment through to (012) 673 2800 for the attention of the Finance
Department.
8.
PRESCRIBED MINIMUM BENEFITS
What are prescribed minimum benefits?
In terms of The Medical Schemes Act, medical schemes have to provide minimum hospital
based benefits for certain conditions. These hospital benefits are available even during a
waiting and/or exclusion period. The prescribed minimum benefits cover you for specific
treatments and services as is available in a state facility. A list of the conditions covered is
available on the website of the Council for Medical Schemes at www.medicalschemes.com
If you are unsure about the coverage of a specific condition, enquiries may be directed
to the Scheme. Please note: In addition to the CDL conditions, Hormone Replacement
Therapy for menopause is also covered under the CDL benefit
The scheme also funds the cost of the diagnosis, consultations, procedures and
medication of the specified list of 25 chronic conditions. This list is referred to as the
prescribed minimum benefits “Chronic Disease List” (CDL). These conditions will be
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covered 100% if services are rendered according to the scheme’s treatment plans, CDL
medication lists, and claimed with the correct diagnostic (ICD-10) codes.
TABLE 1: PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL) (ALL
OPTIONS)
1. Addison’s Disease
14.Epilepsy
2. Asthma
15.Glaucoma
3. Bipolar Mood Disorder
16.Haemophilia
4. Bronchiectasis
17.Hyperlipidaemia
5. Cardiac Failure
18.Hypertension
6. Cardiomyopathy Disease
19.Hypothyroidism
7. Chronic Renal Disease
20. Menopause (HRT)
8. Coronary Artery Disease
21.Multiple Sclerosis
9. Crohn’s Disease
22.Parkinson’s Disease
10.Chronic Obstructive Pulmonary Disease
23.Rheumatoid Arthritis
11.Diabetes Insipidus
24.Schizophrenia
12.Diabetes Mellitus Type 1 & 2
25.Systemic Lupus Erythematosus
13.Dysrhythmias
26.Ulcerative Colitis
TABLE 2.1: OTHER CHRONIC CONDITIONS (PLATINUM ONLY)
1. Acne*
15.Major depression
2. Allergic rhinitis**
16.Meniere’s disease*
3. Alzheimer’s disease*
17.Menopausal disorder (Calciums only)
4. Ankylosing spondylitis
18.Myasthenia gravis
5. Benign prostatic hypertrophy
19.Osteoarthritis
6. Clotting disorders
20.Osteoporosis#
7. Cystic fibrosis
21.Paraplegia, quadriplegia##
8. Deep vein thrombosis
22.Peripheral vascular disease
9. Diverticulitis and Irritable bowel
syndrome
23.Psoriasis*
10. Gastro-oesophageal reflux disorder
25.Stroke
11.Hypoparathyroidism
26.Testosterone deficiency*
12.Hyperthyroidism
27.Urinary incontinence
13.Interstitial fibrosis
28.Hyperkinesis (Attention deficit
disorder)
14.Iron deficiency anaemia
24.Rheumatic fever
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MEMBERGUIDE 2008
TABLE 2.2: OTHER CHRONIC CONDITIONS (GOLD)
1. Acne*
13.Meniere’s disease*
2. Allergic rhinitis**
14.Menopausal disorder (Calciums only)
3. Ankylosing spondylitis
15.Myasthenia gravis
4. Benign prostatic hypertrophy
16.Osteoarthritis
5. Cystic fibrosis
17.Osteoporosis#
6. Deep vein thrombosis
18.Paraplegia, quadriplegia##
7. Gastro-oesophageal reflux disorder 
19.Peripheral vascular disease
8. Hypoparathyroidism
20.Psoriasis*
9. Hyperthyroidism
21.Rheumatic fever
10.Interstitial fibrosis
22.Stroke
11.Iron deficiency anaemia
23.Testosterone Deficiency*
12.Major depression
28.Hyperkinesis (Attention deficit disorder)
RULES APPLICABLE TO THE CHRONIC MEDICATION BENEFIT
Chronic medication requests for certain conditions (*) will only be considered if
prescribed by an appropriate specialist e.g:
• A dermatologist prescription is required for chronic medication for Acne and Psoriasis
• An ENT or neurologist prescription is required for chronic medication for Meniere’s
disease
• A neurologist or psychiatrist prescription is required for chronic medication for
Alzheimer’s disease
• A urologist or physician prescription is required for chronic medication for
Testosterone deficiency
Chronic medication for Allergic rhinitis (**) will be considered if prescribed by a specialist
(ENT, paediatrician or physician). Prescriptions will be considered from a general
practitioner if:
• The condition is severe or associated with asthma in children
• There is associated asthma in adults
• Prescriptions for Gastro-oesophageal reflux disorder (GORD) () from a general
practitioner may only be authorised for a total duration of 2 months. Thereafter a
gastroenterologist, physician or general surgeon’s prescription is required
Chronic medication for Osteoporosis (#) will only be considered on submission of a Bone
Mineral Denisity (BMD) scan.
Chronic medication for Paraplegics and Quadriplegics (##) will be considered for urinary
and bowel complications only.
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The following medicines are EXCLUSIONS FROM THE CHRONIC MEDICINE
BENEFIT:
• Vitamins and mineral preparations (excluding calciums for postmenopausal females
and patients with hypoparathyroidism and chronic renal disease)
• Homeopathic medication
• Hypnotics and anxiolytics
• Mucolytics and decongestants
The following conditions REQUIRE SPECIAL AUTHORIZATION DIRECTLY FROM
THE SCHEME.
Please contact the following number for authorization/registration:
• Oncology and organ transplant: 086 067 1060 or fax 012 671 8748
• HIV/AIDS: 086 050 6080 (Lifesense)
9.
PRESCRIBED ACUTE MEDICATION
Acute medication is medication prescribed once for less than one month by a medical
practitioner, or medication for conditions not recognised as chronic conditions by the
scheme. Acute medication is subject to the application of MMAP (Maximum Medical Aid
Price).
Example: Antibiotics prescribed for tonsillitis.
Where does a member obtain acute medication?
The medication may be obtained from any pharmacy of the member’s choice, or from
a dispensing medical practitioner. Homeopathic medicine is subject to the day to day
benefit.
9.1 To take out medication (TTO)
Medication provided to you upon discharge from hospital is limited to a R300 benefit per
annum on Platinum, Gold, Silver and Bronze benefit options. Once this limit has been
reached your day to day benefit will come into effect. Should you receive a prescription for
medication upon discharge from the hospital, it doesn’t qualify as TTO anymore, but as a
day to day benefit.
10. SELF MEDICATION
Self medication (over-the-counter medication) is medication with a “NAPPI” code that
can be obtained from a pharmacy without a prescription. The pharmacy either claims the
amount directly from KeyHealth, or the member pays the pharmacy in cash and claims the
amount from KeyHealth by forwarding the specified account and receipt. Self medication
has a sub limit which is subject to the combined day to day limit per option. The Bronze
option offers no self medication benefit.
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MEMBERGUIDE 2008
11. PRESCRIBED CHRONIC MEDICATION (Life-sustaining
Medication)
Chronic medication is medication used for more than a month for conditions as contained
in Tables 1 and 2. The AAL is a list of chronic medication that was approved by KeyHealth.
The Automatic Authorisation List does not list all medication that may be required to treat a
patient’s condition. Some medication requires specific pre-authorisation. This authorisation
will be limited to a specific period depending on your prescription and the motivation. As
detailed clinical information is required to pre-authorise these drugs, the treating doctor is
requested to obtain this authorisation from SwiftAuth OnLine™ on the following number:
0800 132 345. No authorisation forms are required. (Please refer to the Medikredit and/
or KeyHealth websites for a complete list of chronic medication (AAL).
Please note: The AAL is not a fixed list of products. This list is continuously being
revised with regard to new products being registered, products that no longer exist, price
changes, maximum medical aid prices (MMAP®) that change, and changes to the product
registration details.
The AAL is divided into 2 sections:
Section 1 – PMB CHRONIC DISEASE LIST (CDL)
Applies to Platinum, Gold, Silver, Bronze and KeyCap
Includes:
• formulary drugs for the treatment of the PMB chronic diseases in accordance with the
legislated therapeutic algorithms
• non-formulary drugs – a reference price may apply to these products
• Maximum Medical Aid Price (MMAP®) applies to specific drugs that are above
MMAP®. Drugs that are within the maximum medical aid price are included in Section
1. If a product that is above the maximum medical aid price is prescribed, the patient
will need to pay the difference in price at the point of dispensing.
CDL medication can be obtained from any pharmacy or dispensing doctor of your choice,
except for Silver and Bronze members. Silver and Bronze members should obtain their
CDL medication from the designated service providers. If not, a 30% co-payment will be
charged. KeyCap members must obtain their CDL medication from the PrimeCure network
designated service provider.
Section 2 – DRUGS FOR OTHER CHRONIC DISEASES (Non-PMB CDL conditions)
• Access to a benefit for these conditions is only available on Platinum and Gold
• A VARIABLE CO-PAYMENT applies to all drugs in Table 2 as well as telephonically
pre-authorised drugs for these conditions.
• The co-payments are as follows:
ƒƒ Platinum
10% of the cost
ƒƒ Gold
15% of the cost
This means that the chronic medication benefit on Silver and Bronze is limited to
medication for the CDL conditions.
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• Certain products will only be automatically authorised if prescribed by the appropriate
specialist. In certain circumstances these drugs may be authorised by other
prescribers who should contact the SwiftAuth OnLine pre-authorisation helpdesk for
further information on 0800 132 345
Authorisation of chronic medication is subject to the following:
Patients can only access chronic medication if they have REGISTERED their chronic
condition(s) with SwiftAuth OnLine™ on the following number: 0800 132 345
This applies to all eligible chronic conditions.
Newly diagnosed chronic conditions
If a patient is diagnosed with one of the chronic conditions listed in table 1 and/or 2,
then registration of the chronic condition is required before access to chronic medication
benefits will be granted.
Who can register the chronic condition?
As detailed clinical information, including the condition’s ICD 10 code and severity status,
are required to register a patient’s chronic condition, only the treating doctor may register
the patient’s chronic condition.
Once a patient’s condition has been registered, a patient will have access to the
AUTOMATIC AUTHORISATION LIST (AAL). This is a list of drugs, appropriate for the
condition, that do not require pre-authorisation – they are automatically authorised.
The AAL includes FORMULARY drugs – these are drugs that are available to all patients
with the specified condition to which no reference price apply, providing they are claimed
in appropriate quantities.
Reference pricing may apply to NON-FORMULARY drugs for both PMB (CDL) and nonPMB conditions, in accordance with the benefit option selected by the patient.
12. REFERENCE PRICING
Certain products on the AAL have reference pricing applied. This reference price differs
on each benefit option.
The reference price is based on the cost of drugs from a similar drug class listed on the
FORMULARY to which no reference price applies. The patient is required to pay the
difference between the cost of the drug and reference price of the formulary drug at the
point of dispensing.
If chronic medication is required, the following procedure should be followed:
1. If it is a newly diagnosed condition your doctor will have to register this condition with
Medikredit. The doctor can also call the SwiftAuth Online toll free number (0800 132
345) to discuss your medication and to obtain telephonic authorisation for medication
that does not appear on the AAL.
2. Your doctor will then issue a prescription so that you can obtain the medication from
your local pharmacy, the Scheme’s DSP pharmacies or your Doctor’s dispensary.
15
MEMBERGUIDE 2008
Your pharmacist will submit a claim by means of the MediKredit Healthnet facility in
terms of the Scheme’s benefit for chronic medication.
Please note: Only doctors and pharmacists may make use of SwiftAuth OnLine’s toll free
line. Members and patients may not use the toll free line, but can obtain further information
from SwiftAuth OnLine’s patient helpline by phoning (011) 770 6200 weekdays from 08:00
until 17:00.
3. If certain medication is still not authorised after discussion with your doctor, you can
obtain it from your local pharmacy or doctor by paying for it, or by claiming it against
your day to day benefit.
4. Maximum Medical Aid Prices (MMAP®) will apply to certain medication. Generic
equivalents that fall within the maximum medical aid price are available. If the doctor
should prescribe a product that exceeds the maximum medical aid price, you as a
member will be responsible for paying the price difference when you purchase the
medication.
13. MAXIMUM MEDICAL AID PRICE (MMAP®)
MediKredit, a service provider of KeyHealth, determines the MMAP® price levels by
conducting surveys in the medicine market and is responsible for the institution of MMAP®.
MMAP® is a programme through which the maximum price your scheme is prepared to
pay, for specific categories of generic medication. This means that if you should choose
to receive the MMAP® product, which will be within the permitted limits, KeyHealth will
pay the full price of this product (excluding any possible levies that may be applicable). If,
however, you prefer to choose medication that is more expensive than this price, you will
be responsible for the price difference.
MMAP® products have been chosen because they are tested, tried and approved by the
Medicines Control Council. The approval is based on evaluation criteria that determine that
the product may be regarded as the pharmaceutical equivalent (also known as “generic
product”) of other popular brands. The composition and effect of the generic products are
thus the same, but they may differ in price.
To stretch your benefits further and to affect savings on your medical costs, we advise
you to ask the doctor to prescribe generic medication where possible. Products below
the MMAP® price have no co-payment on acute medicine. Should you be liable for a
co-payment on your acute medicine, it is due to the fact that your medicine provider
charges more than the recommended price.
14. MANAGED HEALTH CARE
These programmes are all subject to management protocols as agreed upon by the
scheme.
14.1 PRE-AUTHORISATION OF HOSPITAL ADMISSIONS
KeyHealth has contracted with Multimed to manage the utilisation of hospital benefits.
Before a member can be admitted to hospital, the member should phone 0860 671 060
MEMBERGUIDE 2008
16
for authorisation. The following information must be provided when you call during office
hours between 7:30 and 17:00:
1. Your membership number;
2. The full name of the patient being hospitalised;
3. The name and practice number of the hospital to which the patient will be admitted;
4. The reason for the hospital admission or the planned diagnostic procedure and
ICD-10 or CPT4 code;
5. The date of admission and the date on which the procedure is scheduled to be
carried out;
6.The particulars of the doctor or service provider (practice number, initials, surname
and telephone number).
Always ask your doctor for a full description of:
ƒƒ The reason for admission;
ƒƒ The associated medical diagnosis;
ƒƒ The prospective procedures as well as the procedure code he/she intends to use.
Please note that a pre-authorisation reference number does not guarantee that all costs of
the authorised procedure will be paid. Benefits will be paid according to what is permitted
in terms of the rules of KeyHealth. Services must commence within thirty days of
approval and will be subject to the benefits of the year in which the services are
rendered.
Once the abovementioned information has been processed, the member is provided with
an authorisation number. If no authorisation number was obtained, no benefits will be
payable. In an emergency, however, it is not necessary to obtain an authorisation number
in advance.
PLEASE NOTE:
You need to pre-authorise three (3) working days prior to an admission, or within 24 hours
after an emergency admission (your family members, friends or hospital can call on your
behalf if you are unable to), otherwise no benefits will be paid.
Surgical procedures performed in doctor’s rooms:
Certain surgical procedures performed in doctor’s rooms are subject to in-hospital
benefits.
List of procedures:
Colonoscopy
Gastroscopy
Sigmoidoscopy
Laser tonsillectomy
Circumcisions
Vasectomy
Cataract surgery
17
MEMBERGUIDE 2008
Lens implants
Every year KeyHealth negotiates special tariffs with hospital groups using the NRPL as the
basis for stipulating these tariffs. Should members receive accounts requesting additional
payments for hospitalisation, kindly contact the Client Service Centre on 0860 67 1050
prior to making any payments.
Emergency numbers for after-hours emergencies: 0860 67 1060
This facility should be used for emergencies and after hours. Note: This number is also
available on weekends and public holidays.
15. CASE MANAGEMENT
This is an individual programme aimed at providing quality health care as an alternative
to hospitalization.
15.1.PREGNANCY MANAGEMENT PROGRAMME
Registration on the pregnancy management programme is compulsory. The expectant
mother should join this programme after 12 weeks of pregnancy. If she fails to do so, she
will be liable for all hospital costs incurred. Call 0860 671 060 to register. Two ultrasounds
per pregnancy are permitted. The first is usually taken between 10 and 14 weeks and
the second between 20 and 24 weeks. Any further ultrasounds needs to be motivated in
writing, by the doctor, and sent to KeyHealth for consideration.
15.2.ONCOLOGY MANAGEMENT PROGRAMME
Why is there a cancer management programme?
• To ensure optimal, appropriate and cost-effective CANCER therapy.
• To work together with your oncologist or treating physician in an effort to negotiate and
authorise funding for treatment.
• To involve you as a member during your therapy.
Your doctor has to complete a cancer treatment plan
• To ensure registration on the programme.
• To facilitate the evaluation of your treatment and to ensure the final approval of your
treatment.
• A completed treatment plan will also ensure processing of the application (to provide
you with your Oncology treatment authorisation), that will ultimately result in speedy
processing of Cancer related claims. The treating doctor may fax your treatment plan
to 0866040652 /51
Separate authorisation numbers for my total treatment
Separate numbers are issued for chemotherapy, radiotherapy (radiation), hospitalisation,
radiology (X-rays) and blood tests. An authorisation number should be obtained for each
procedure.
MEMBERGUIDE 2008
18
In respect of the following you should call 0860 671 060 for authorisation:
• Chemotherapy treatment at the doctor’s rooms
• Chemotherapy treatment during hospitalisation and on an outpatient basis at the
hospital
• Radiotherapy, MRI and CT scans
Cancer follow-up management programme
After completing the cancer treatment programme, members can register with the
KeyHealth Oncology Case Manager to manage follow-up treatments, related to the original
diagnosis. Consultations and medication related to the original diagnosis and approved by
the KeyHealth Oncology Case Manager, will not be subject to the day-to-day benefits of
the member. Contact the KeyHealth Oncology Case Manager at 0860 671 060 to register
for the cancer follow-up management programme.
15.3.ORGAN TRANSPLANTS AND DIALYSIS
Organ transplant/dialysis requires a pre-authorisation number. Organ transplant and
dialysis approvals are subject to the following maximums:
Platinum– 100% unlimited according to medical scheme tariffs (MST)
Gold – Subject to an overall limit of R100 000 per family every two years
The scheme will only pay for the cost of the donor if the donor is also a beneficiary of
KeyHealth.
Silver and Bronze – Only available in state hospitals as part of the PMB’s with no benefits
for harvesting.
Keycap – Only available from designated service provider for PMB.
16. DISEASE MANAGEMENT
16.1.DIABETES
If you are newly diagnosed with Diabetes, your doctor should register your condition with
SwiftAuth OnLine on 0800 132 345.
All medication for diabetes must be supplied through the designated service provider
pharmacies, Atlas Pharmacy (Durban), Atlas Pharmacy (Pietermaritzburg), Umhlatuze
Pharmacy, Medipost and Chronicare Medicine Dispensary. This is applicable to the
Platinum, Gold, Silver and Bronze options. This is in terms of legislation that allows the
scheme to appoint DSP’s for certain chronic conditions. Should members receive their
diabetic medication from any other provider, it will NOT be paid by KeyHealth.
Members can visit the doctor of their choice, as no DSP has been appointed for these
services.
All new diabetics will receive a Glucometer (Rosch) free of charge, from one of the
Designated Service Providers.
Please Note: The Scheme will only fund the Rosch glucose strips from the chronic benefit.
Should you make use of different glucose strips, this would be for your own pocket.
19
MEMBERGUIDE 2008
16.2 HIV MANAGEMENT PROGRAMME
KeyHealth has contracted with LifeSense Disease Management to manage the HIV/AIDS
management programme.
How to register on the programme?
• Contact LifeSense Disease Management on 0860 50 60 80.
• The member of the scheme can go to any doctor of his/her choice for the initial
examination. The doctor will complete the application/pre-certification form together
with the member and forward the form and results of any blood tests to LifeSense.
• A treatment plan based on the above information will be approved by the Medical
Advisor of LifeSense.
• The member’s doctor will be contacted and advised what medication options are
available, taking into consideration the stage of the disease. An application form must
be completed and returned to LifeSense before any medication can be authorised.
How to utilise the HIV management programme?
Once the member is enrolled on the programme, he/she will remain with the chosen
doctor and will be contacted on a regular basis by the Case Manager on behalf of
LifeSense Disease Management, who will provide assistance and support and reinforce
the importance of the correct utilisation of the authorised medication.
The member will also be assisted with lifestyle adjustments and counseling.
Benefits:
The HIV benefits are 100% of the NRPL, provided that the member is enrolled on the
management programme.
In order to qualify for the above benefits, the following conditions will apply:
• LifeSense will only authorise medication through Atlas (Durban), Atlas
(Pietermaritzburg), Umhlatuze Pharmacy, Medipost and Chronicare Medicine
Dispensary, who is the preferred providers of antiretroviral medication for KeyHealth
members, once the applicant has been enrolled on the programme.
• Blood tests – a maximum of 3 HIV monitoring pathology tests per year. Blood tests
must be done at the request of the Case Manager, who will remind the member when
blood tests are to be done.
Enquiries related to HIV claims should be directed to KeyHealth at 0860 671 050
17. DENTAL BENEFIT MANAGEMENT
Denis (Dental Information Systems (Pty) Ltd) manages your dental benefits on behalf of
KeyHealth.
Dentistry benefits have no financial limits, instead there is a set of procedures that are
covered under the KeyHealth tariffs (see www.denis.co.za for the full list of dental tariffs).
Benefits for dentistry are paid on a fee for service basis. The fee charged for every
procedure may differ from dentist to dentist. Your scheme pays a benefit for each
MEMBERGUIDE 2008
20
procedure which may differ from the fee charged by your dentist. It is your right to negotiate
a lower fee with your dentist.
The scheme benefit can be viewed on www.denis.co.za or at your dentist’s rooms.
Benefit for specialists are generally one third higher than dentists so you are not financially
inconvenienced for seeing a specialist.
Benefits are paid to ANY dentist of your choice.
Send all dental claims to:
Private bag X26
Rondebosch
7701
Please call Denis for benefit pre-authorisation for ALL specialised treatment i.e.
crowns, implants, orthodontics and hospitalisation on 0860 104 926. Please note that late
authorisation (after treatment has happened) will result in the scheme paying 20% less for
the treatment. This does not apply to emergencies.
For all your dental queries which include, pre-authorisation for hospital admission,
specialised dentistry for dental cases, claims and benefit queries please call the KeyHealth
dental help desk at 0860 104 926.
Specialised Dentistry
Conservative Dentistry
“Full benefit” means that the procedure is paid at 100% of the scheme rate with no limits.
Auth
required
Y/N
Platinum
Gold
Silver
Consultations,
Oral hygiene,
Extractions,
Fillings
No
Full benefit
Full benefit
Full benefit
Root canal
No
Full benefit
Full benefit
Full benefit
Plastic Dentures
No
Full benefit one per
jaw every 4 years
Crowns &
bridges
Yes
80% of scheme tariff.
3 crowns per family
per year. Clinical
motivation required
for additional crowns
Metal frame
dentures
No
Orthodontics
(braces)
Yes
Implants
Yes
Necessary
Surgery needed
No
100% of scheme
benefit two frames (a
upper and a lower) in
5 years
Comprehensive
100% of scheme rate
Restricted (read note
in this guide)
Full benefit
21
Full benefit one
Full benefit one per
per jaw every 4
jaw every 4 years
years
75% of scheme
tariff. 1 crown per
family per year.
No Benefit
Clinical motivation
required for
additional crowns
100% of scheme
benefit one frame (a
No benefit
upper or a lower) in
5 years
Comprehensive
Preventative
75% of scheme rate treatment only
No Benefit
No Benefit
Full benefit
Full benefit
MEMBERGUIDE 2008
Hospital and Anaesthetics
Hospitalisation
Laughing gas in
dental rooms
IV conscious
sedation in
rooms
General
anaesthetic in
hospital
Auth
required
Y/N
Platinum
Yes
Admission protocols
apply
No
Full benefit
Full benefit
Full benefit
Yes
Clinical protocols
apply
Clinical protocols
apply
Clinical
protocols apply
Yes
Admission protocols
apply
Gold
Silver
Admission protocols
Admission
apply
protocols apply
Admission protocols
Admission
apply
protocols apply
Consultations
There is no limit on the number of times a dentist may be visited, but only two check-ups
per year are covered (a proper check up takes about 20 minutes, x-rays are taken and
the dentist prepares a treatment plan). Other visits are either part of an existing treatment
plan or for emergencies.
Anxious Patients
Some people are anxious about dental treatment and mild sedation is sometimes required.
Benefits are payable without pre-authorisation for in room sedation such as Nitrous
Oxide (laughing gas) or oral sedative preparations. Intravenous conscious sedation
requiring a second professional (doctor) to administer sedatives via a drip does require
pre-authorisation. Hospitalisation and general anaesthetic is not covered where patients
require anxiety control, but only when the treatment is beyond normal physical tolerance.
Crowns
Crowns and bridges are limited per tooth unit per family (see schedule) regardless of the
type of crown being done. Benefits are subject to pre-authorisation.
Orthodontics (braces)
Benefit for orthodontic treatment is subject to benefit pre-authorisation. Benefit will only
be granted to cases assessed as mandatory as per an orthodontic index. Benefits for
Orthodontic treatment are granted as per scheme tariff per procedure code but limited
to beneficiaries whose treatment commences before their 18th birthday. The applicable
tariff is paid as follows: A deposit when the treatment starts and the balance of the tariff
paid over the estimated treatment period. This only applies to comprehensive treatment.
The member is responsible for paying the deposit and the outstanding balance for the
treatment period.
Removable functional appliances (preventative treatment) are paid in full on placement
of the appliance. Please note that only one family member may commence treatment in
a calendar year except in the case of identically aged siblings. Preventative orthodontic
treatment is usually only appropriate in children under 10 years of age and the goal of this
treatment is to reduce the necessity of comprehensive treatment later.
MEMBERGUIDE 2008
22
No benefit is provided for jaw correction surgery (orthognathic surgery) or the hospitalisation
required. Such surgery is planned BEFORE orthodontic treatment starts. Where such
surgery is performed the member is liable for the cost of the surgery and the cost of the
hospitalisation.
Lingual orthodontics and orthodontic re-treatment will not be covered.
Implants (only available on Platinum)
Benefits for implants are limited to 80% of the scheme tarrif. Benefits are subject to preauthorization. Benefits for implant components are limited to R 2500 per beneficiary per
year. The member is always liable for the cost of implant components that exceeds the
­R2500 limit. Hospital benefits are not available for dental implantology. Obtain benefit preauthorisation from Denis to determine benefit allocation before commencing treatment.
Sinus lifts and bone augmentation procedures required for implants are not covered.
Periodontics
Benefit for gum disease is restricted to conservative, non-surgical therapy only (root
planing).
This benefit is only available to those members on the Alpha and Sigma options who are
registered on the Perio Programme.
To apply for the Perio Programme, submit your CPITN score (supplied to you by your
dental practitioner), together with your Periodontal treatment plan to perio@denis.co.za or
alternatively fax to (021) 673 6633.
Further clinical records may be requested to process your application.
Periodontal benefits will be applied to cases assessed as periodontally compromised, as
per the CPITN score.
Surgical periodontics is a scheme exclusion.
Dental Benefit Exclusions (detailed list available on www.denis.co.za)
The following treatment does not attract benefit (member is liable for cost)
• Orthognathic (jaw correction) surgery is not covered except in the case of severe facial
deformities (rather than occlusal imbalances) and where specifically allowed by the
scheme
• Bleaching, front tooth laminate veneers and composite veneers
• Porcelain or resin inlays except where the inlay forms part of a bridge
• Metal inlays except where such inlay forms part of a bridge
• Fissure sealants are not covered on patients older than 16 years
• Electrognathographic recordings and other such electronic analyses
• Fixed prosthodontics used to repair multiple teeth damaged due to grinding
• Oral hygiene instructions, nutritional and tobacco counselling
• Cost of implant components
• Laboratory fabricated crowns are not covered on primary teeth or third molars
• No benefit for metal base to full denture (including laboratory cost of metal base)
23
MEMBERGUIDE 2008
• Endodontic procedures on third molars unless clinically motivated
• Cost of gold
• Polishing of restorations
• Ozone therapy
• Snoring appliances
• Laboratory cost relating to clinical procedures which are not covered are also not
covered
Hospitalisation benefits
Hospitalisation for dentistry is not automatically covered and is subject to benefit preauthorisation where the following protocols apply:
• Hospitalisation cover is provided where an underlying medical condition creates a
substantial increased risk of treatments in the rooms and indicates that higher level of
care is required.
• The requirement of a sterile facility is not on its own an acceptable reason for
hospitalisation benefits for dental treatment
• Hospitalisation cover is provided when the treatment envisaged is of such a nature
that it can not normally be tolerated by an average person without general anaesthesia
• Hospital benefits for the removal of impacted teeth will be covered when the tooth is
classified as a hard tissue (bony) impaction and is associated with pathology or severe
pain
• Hospitalisation benefits are not available for dental implantology or procedures
associated with dental implantology
• Multiple visits to theatre for young children will not be covered i.e. a single hospital visit
should suffice to stabilise the dentition until the child is old enough for normal dental
treatment
18. MEDICAL APPLIANCES
Medical appliances can be described as medical equipment used for the treatment and/or
cure of a medical condition.
The medical appliances benefit includes items such as nebulisers, apnoea monitors or
apnoea mattresses, as well as orthopaedic appliances and incontinence equipment.
These appliances are subject to annual limits according to your benefit option. Platinum
limited to R5 775, Gold R3 500 and Silver R1 200 per family per annum. Bronze has no
medical appliance benefit.
Pre-authorisation is necessary for most of the medical appliances. For pre-authorisation
fax your doctor’s motivation as well as a quotation to: 086 604 0686
Orthopaedic appliances includes neck- and back braces, orthopaedic shoes, elastic
stockings, wheelchairs, walking frames, crutches, corsets, splints, slings, foam walkers,
innersoles and safe-hip prosthesis.
Incontinence equipment includes nappies for adult use.
MEMBERGUIDE 2008
24
If you are not sure whether a certain item is indeed covered, you can refer to the list of
exclusions at the back of this guide. Please note that all medical appliances require a
motivation letter and a quotation.
19. HEARING AIDS AND MAINTENANCE
Hearing aid benefits on the Platinum option is limited to R15 000 per family over a 4 year
period, with a R700 maintenance benefit per beneficiary per annum.
The hearing aid benefit on Gold is limited to R5 000 per family over a 4 year period, with
a R500 benefit on hearing aid maintenance per beneficiary per annum.
The benefit on Silver is subject to the combined medical appliance benefit of R1 200.
Bronze has no hearing aid benefit.
20. INTERNAL AND EXTERNAL PROSTHESIS
INTERNAL PROSTHESIS
Platinum
Gold
Overall annual limit per
family per annum
High cost
Cardiac stents
Silver
Bronze
R40 000
R25 000
R10 000
R10 000
R40 000
R25 000
R10 000
R10 000
Pacemakers
Hip replacements
Sphincters & stimulators
Internal defibrillators
(per incident – subject to overall benefit)
Aortic stents
Heart valves
Anti embolic devices
Cerebral stents
Knee replacements
Cochlear implants
Medium cost
Spinal instruments
R20 000
R12 500
R5 000
R10 000
Peripheral stents
Internal fixation devices
(per incident – subject to overall benefit)
Lumbar disc prosthesis
Elbow replacements
Ankle replacements
Bone lengthening
External Prosthesis/
Other: eg. An artificial
leg, lens implants
No benefit
R10 000
R6 500
25
R2 000
Subject to case
management
MEMBERGUIDE 2008
Please note: If internal prosthesis limits are exceeded on Platinum, the member will be
liable for a 20% co-payment on the difference.
21. OPTICAL BENEFITS
Optical benefits on Platinum have no overall limit and are structured to provide each
patient with the appropriate clinical solution. One set of lenses and a R850 benefit on
frames per beneficiary, every two years apply. A sub limit of R1 300 on contact lenses is
available per year. Refractive surgery has a benefit of R5 250 per family. Over the counter
reading glasses are limited to R120 per beneficiary annually. One eye test is allowed per
beneficiary every two years.
Gold has an overall limit of R1 500 per beneficiary every two years which includes a frame
benefit of R500. One set of lenses every two years apply. A sub limit of R 800 on contact
lenses is available per year (subject to overall limit), but limited to either contact lenses or
spectacles. A R100 benefit not subject to the overall limit, is available for over the counter
reading glasses per beneficiary per year. Refractive surgery is subject to the overall limit.
One eye test is allowed per beneficiary every two years.
Silver has an overall limit of R750 per beneficiary every two years which includes a R400
frame benefit. One set of lenses every two years apply. A sub limit of R 400 on contact
lenses is available per year (subject to overall limit), but limited to either contact lenses or
spectacles. One eye test per beneficiary is permitted every two years. Refractive surgery is
subject to the overall limit. An annual R80 benefit not subject to the overall limit, is available
for over the counter reading glasses per beneficiary.
Pre-authorisation is required for refractive surgery on all benefit options.
No optical benefits are available on the Bronze option.
Please note: The periods mentioned above is applied from the date of service.
All optical benefits are subject to the optical management program and clinical necessity.
Platinum
Gold
Silver
Subject to Optical benefit management program and clinical necessity
R 1500 per beneficiary R 750 per beneficiary
Overall Limit
No limit
per 24 month period
per 24 month period
Eye Examinations: One (1) exam per beneficiary per 24 month period
100% of Tariff for eye
100% of Tariff for eye
100% of Tariff for eye
Eye Exam
exam
exam
exam
Lenses: One (1) pair of spectacle lenses per beneficiary per 24
month period
Single vision, Bi-focal
100% of Tariff for
100% of Tariff for
100% of Tariff for
and Varifocal lenses:
generic lenses
generic lenses
generic lenses
MEMBERGUIDE 2008
26
Platinum
100 % of Tariff for
the generic add-on
for generic glass
photochromic lenses
or
100 % of Tariff for the
generic add-on for
generic fixed tint not
exceeding 35%
or
100 % of Tariff for the
generic add-on for
generic hard-coating
Gold
Silver
100 % of Tariff for
100 % of Tariff for
the generic add-on
the generic add-on
for generic glass
for generic glass
photochromic lenses
photochromic lenses
or
or
Add-ons (tints,
100 % of Tariff for the
100 % of Tariff for the
coatings, powers,
generic add-on for
generic add-on for
designs, materials,
generic fixed tint not
generic fixed tint not
branded lenses):
exceeding 35%
exceeding 35%
or
or
100 % of Tariff for the
100 % of Tariff for the
generic add-on for
generic add-on for
generic hard-coating
generic hard-coating
Contact Lenses:
R400 per beneficiary
R 800 per beneficiary
every year, limited to
R 1 300 per beneficiary every year, limited to
Clear contact lenses:
every year
spectacles OR contact spectacles OR contact
lenses
lenses
Frames: One (1) frame per beneficiary per 24 month period
Frames:
R850 per beneficiary
R500 per beneficiary
R400 per beneficiary
22. EMERGENCY TRANSPORT: Netcare 911 (082 911)
Netcare 911– Medical Scheme Cover provides medical scheme members with
unlimited emergency service benefits while managing the medical care provided to
members in the pre-hospital environment, including all associated transportation costs, on
behalf of Keyhealth.
emergency benefit:
• Emergency response by road or air ambulance to the scene of incident
ƒƒ Emergency response is provided via the Netcare 911 Call Centre, by means of
dialing 082 911 nationally
ƒƒ Vehicles or aircraft are dispatched electronically by means of Vehicle Tracking
Protocol (ensuring the closest resource is sent to the scene)
• Transfer by road or air to the most appropriate medical facility
ƒƒ The road and air services on scene would ascertain the most appropriate medical
facility in the closest proximity, equipped to deal with the patients’ condition most
effectively, and the transfer is at no charge for the member
ƒƒ Protocols followed for air-transportation is determined by clinical evaluation of the
patients’ condition, as well as time-factors
ƒƒ Road services are provided by a National fleet of 235 response vehicles and
ambulances
ƒƒ Helicopter services are provided by, 2 day-time helicopters in Gauteng and 1 nighttime service
27
MEMBERGUIDE 2008
ƒƒ 5 Coastal helicopters provide services on the KZN Coast and full Cape Coast, in
co-operation with Surf Lifesaving SA
ƒƒ Fixed wing services are provided by 3 long-range medical jets
ƒƒ Air services are complemented Nationally by the co-operation of Emergency Medical
Air service providers
• Medically justified transfers to special care centres/inter-hospital transfers as
authorised by the Medical Director, according to the NETCARE 911 protocol
ƒƒ The medical scheme provides Netcare 911 with clinical and rule-based guidelines to
determine Interhospital Transfers
ƒƒ Members have to ensure the Hospital or Medical Facility they are in, contact 082
911 for the arrangement of the transfer
ƒƒ Netcare 911 provides 5 full-time doctors to assist with medical assessment of
Interhospital Transfers
• Transfer of life saving medication/blood to the scene of the incident
ƒƒ In cases where the patient is on scene for extended periods (such as in vehicle
extractions) and require medication or blood, Netcare 911 would ensure the
necessary products get to the scene of the incident as soon as possible
• Companionship and/or care of stranded minors
ƒƒ In a medical emergency where the patient is accompanied by minors (uninjured), the
said minors would be taken care of until such time as Netcare 911 can hand these
minors over to the care of family or care services
• Repatriation of patient if hospitalised far from home
ƒƒ In cases where a patient was hospitalised far from home (i.e. where a person
encountered a medical emergency on holiday), Netcare 911 will move this patient
closer to home, given that the period of hospitalisation would be another 7 days or
longer, and the patient is stable enough to transfer by road or air
• Repatriation of mortal remains
ƒƒ In the unfortunate event of a death occurring away from a members’ natural
residence(i.e. whilst on holiday), the mortal remains would be transferred to the
members’ place of natural residence
• Access to Rape Crisis Centres of Excellence
ƒƒ Members exposed to medical emergencies of a sexual nature, would be transferred
to Rape Crisis Centres of Excellence
ƒƒ These Centres provide a one-stop service, from the taking of Police statements,
Counselling, Anti-retroviral protocols, and the full provision of sexual assault kits for
forensic purposes
• Free advice via the SAA/Netcare Travel Clinics
ƒƒ Netcare Travel Clinics provide an information based service for members travelling
nationally and internationally on the medical requirements and preventative
treatment for said travel
MEMBERGUIDE 2008
28
ƒƒ This information service is free of charge, and members would be fully advised by
calling (011) 674 3654
Emergency Telephonic “911” Medical Advice and Information
• 24 hours a day medical advice, offered in English, Afrikaans and most official
languages of South Africa
• General non-emergency medical advice
• Advice on closest appropriate medical facilities
• Guidance on medication and possible side-effects
• Emergency telephonic “CPR”
• Triage of all calls and escalation to on-site doctor in the 24 hour Global Response Call
Contact Centre
• Immediate transfer and escalation to emergency dispatch should immediate
intervention be required.
Frequently asked questions:
Why do I need to contact Netcare for authorisation?
• Members are sometimes unsure of when to use an ambulance. Netcare 911 will
ensure that ambulance services are utilised appropriately so that the emergency
ambulance infrastructure is available for members genuinely requiring medical
transportation.
If I am not able to call Netcare myself, will my claim still be paid if someone else
calls on my behalf?
• Yes, the claim will be paid provided that the reference number is indicated on the
account and if you were genuinely unable to call yourself.
Will Netcare 911 pay my ambulance account even if they were not used?
• Provided the emergency call was received on 082 911.
• If it was an emergency and the member was unable to call.
• The transport was medically justified.
When will Netcare 911 not pay the ambulance account?
• If not medically justified.
• If Netcare 911 was not contacted in an emergency situation
• For an inter-hospital transfer where pre-authorisation has not been obtained from
Netcare 911.
• If the account is received after 120 days or more after the service date.
23. CLAIMS PROCEDURE
KeyHealth strives to make the claims procedure for members as user-friendly as possible
and in most cases claims are submitted by the service provider, i.e. your doctor, dentist,
physiotherapist, pharmacist, etc. on behalf of the member. We must emphasise, however,
that you should check all your claim entries on your claims-advice to ensure that the
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MEMBERGUIDE 2008
services were indeed rendered to you. By doing this you will notice if there were any
inaccurate claims against your benefits. If there appears to be a problem, contact the
service provider and enquire about the claim submitted on your behalf. If services were not
rendered you should then contact KeyHealth and point out the discrepancies as KeyHealth
ensures that you only pay for services you have received.
Claims for cash payments
If, for any reason, you should pay cash for services covered by your benefits, you can
claim this back directly from KeyHealth. Here we refer to certain doctors who claim more
than the Medical Scheme Tariff, as well as cash payments to service providers who offer
a large cash discount, which in turn will ensure that your benefits stretch further. When
you pay cash, please remember to request a detailed account and a receipt as proof
of payment. Clearly mark the account “Refund Member” and ensure that your medical
scheme number is indicated on all documents..
Before you submit your claims, you should ensure that the account shows the following
detail:
• The principal member’s name and initials as it appears on the membership card
• The membership number
• The name of the Scheme and the benefit option
• Your bank details
• The patient’s first name(s) and dependant code as indicated on the membership card
• The name and practice number of the service provider (doctor, hospital, pharmacy, etc.)
• The date of the service or treatment
• The nature and costs of each service and – where applicable – the tariff code (ICD 10
code)
• The referring doctor and practice number in the case of a specialist’s account
• The duration of an operation (where applicable)
• The name, quantity, price and NAPPI code of each item of medication (where
applicable)
If your claim does not contain all the necessary information, it will delay the process,
thus delaying your benefit payment
You are advised to keep copies of all your accounts, receipts and statements for your own
record.
Sign the account and POST the original account and receipt to:
KeyHealth
P.O. Box 14145
LYTTELTON
0140
How will the scheme reimburse you?
Any money owed to you will be paid into your bank account, provided that we have your
banking details. Direct payments into your bank account are hassle free and easy.
MEMBERGUIDE 2008
30
If you are currently being refunded by means of cheque payments, there is a risk that the
cheque will be lost, delayed or stolen in the mail. If you wish to receive direct payment into
your bank account, send your details to our client service centre in writing.
Payments to members are made twice a month.
How soon should claims be submitted?
Claims received within four months of date of treatment or procedure will be paid. Accounts
older than four months and for which no proof of timeous submission can be shown will
not be paid.
Please note: A receipt without the appropriate detailed account will not be paid.
How can you keep a record of claims paid?
Once the claims have been processed, you will receive a claims advice indicating the
following information:
• Amounts paid by the Scheme and to whom payment was made;
• Repayments to you by the Scheme (if any);
• Monies owed to the Scheme by yourself or any service provider (doctor, hospital, etc.);
• The balance of your benefits for the current year.
You will also receive e-mail confirmation of claims processed if we have your e-mail
address on our database.
You should enquire at the client services centre regarding claims submitted which do not
appear on your claims advice.
Claims submitted to the scheme by the provider
Many providers of medical services and pharmacies have an electronic link to the scheme.
This means that they submit their claims on your behalf directly to the scheme. You are
entitled to a copy of this account to follow the processing of this account on your claims
advice.
Outstanding claims on resignation or death
Claims submitted within four months will be paid, provided the service date was prior to
the date of resignation or death.
Why wasn’t my account paid in full? (Shortfalls)
A shortfall is the difference between the actual claim of the medical service and the benefit
paid by the Scheme, in other words where the claim amount exceeds the tariff amount.
Your accounts also won’t be paid in full when your annual benefits are exhausted.
24. SAVINGS ACCOUNT
The use of a Medical Savings Account:
A compulsory savings account is available on the Gold option, the following with regards
to a medical savings account is brought to your attention:
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MEMBERGUIDE 2008
The amount available in the member’s savings account is allocated in advance for the
year.
Any amounts not being used during a specific financial year, will be carried over to the
following financial year.
Provision has been made on KeyHealth for “debt redemption”. This means that should any
moneys be due to the scheme, the amount after debt redemption will be paid out in the
following instances:
• Change of option: Should the selected new option on the scheme not make provision
for a savings
• Resignation: Should you resign from the Scheme during the year and your provisional
Scheme does not have a savings option. The savings amount will be paid out to you
in this regard.
• Resignation: Should you resign from the Scheme during the year and your provisional
Scheme does have a savings option. The savings amount will be paid out to the New
Scheme in this regard.
Should the savings amount that has been allocated to the member, be exceeded before
the 31 December of that respective year, the member will be liable to pay this money over
to the Scheme in the following instances:
• Change of option: should the new option, selected by the member, not make provision
for a savings
• In the event of the member resigning from the Scheme
The following day to day medical expenses will be paid from your savings account:
• Co-payments on Category B chronic medication
• Co-payments on acute medication
• Payments on amounts where the maximum benefits were exceeded
• Payments for services excluded from benefits
• Payment for services rendered during waiting periods; and
• Payment for services rendered in respect of underwriting exclusions
25. GAP-COVER
What is Gap-cover?
Gap-cover comes into effect when the total hospital and related claims of a family exceed
R30 000 on Platinum, R40 000 on Gold, R50 000 on Silver and R30 000 on Bronze per
annum (Prosthesis cost excluded.)
The rules of KeyHealth stipulate that only the Medical Scheme or Agreed Tariff shall
be paid to the service provider. The member will thus be personally responsible for the
payment of the balance to the service provider (eg. a specialist or anaesthetist).
When a member has Gap-cover, the difference between the specialist’s claim and the
scheme’s benefit amount is paid out to the member. However, gap-cover is limited to
MEMBERGUIDE 2008
32
200% of MST on Platinum, 180% of MST on Gold, 160% of MST on Silver and 200% of
MST on Bronze.
If the member should owe KeyHealth money, such debts will be settled before any
payment is made. Thus debts will be paid first and the remaining amount (after payment
of the debt) will then be paid to the member.
26. FOREIGN CLAIMS
To qualify for the payment of foreign claims, you should inform the scheme one month in
advance of your intended travels abroad. You will be covered for the trip, provided your
membership fees are in order/paid.
KeyHealth in conjunction with Netcare 911 offers an exciting benefit. You and your
dependant can travel outside the borders of South Africa with utmost peace of mind. You
will have access to benefits such as:
• Emergency medical cover
• 90 days cover per trip, limited to 180 days per annum
• R5 million cover in respect of medical expenses
On receipt of your proposed travel arrangements the scheme will provide you with more
comprehensive information. You can also visit our website at www.keyhealthmedical for
more details in this regard.
Should you require more than one month’s supply of chronic medication for your overseas
trip you should inform the scheme of the following:
• Name of the country you will be visiting
• Period of visit
• Name(s) of chronic medicine of which you require additional supplies
• Quantities of medicine
• Name of the service provider where you intend to purchase the medicine
• Name of the dependant who needs the medication
Upon receipt of this information you will receive a confirmation letter for your pharmacist
to claim for the medicine.
27. MOTOR VEHICLE ACCIDENTS
Any condition for which compensation can be claimed or which may give rise to
compensation in terms of the Road Accident Fund does not qualify for benefits in terms
of the Scheme, unless a member informs KeyHealth within a reasonable time after the
accident about his/her intention to submit a third-party claim. Claims arising from a motor
vehicle accident with service date from 2006 will be settled against a member’s normal
scheme benefits.
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MEMBERGUIDE 2008
28. INJURY ON DUTY
Medical claims arising from an injury on duty are not covered by KeyHealth. All Injuries On
Duty claims must be claimed from the Compensation Commissioner. If it should happen
that claims applicable to the injury on duty are inadvertently paid by the scheme, the
scheme must be informed, after which adjustments will be made to the claims, and the
amount will be claimed back from the service provider. It is your employer’s responsibility
to ensure that the medical claims are claimed from the Compensation Commissioner.
29. LIST OF EXCLUSIONS
With the exception of the Prescribed Minimum Benefits (PMB) and unless specific
provision has been made in the rules for benefits, no benefits will be payable in respect
of the following:
1. Costs incurred for treatment arising out of an injury sustained by a Member or
Dependant and for which any other third party is liable. The Member is, however,
entitled to such Benefits as would have applied provided that on receipt of payment
in respect of medical expenses the Member will reimburse the Scheme any money
paid out by the Scheme in respect of this benefit.
2. Services for which Benefits are in excess of the maximum Benefits to which the
Member is entitled to, as contained in the Rules.
3. The Cost of services rendered by the following:
3.1 persons not registered with an acknowledged professional institution which
was established or registered in accordance with a government Act; or
3.2 any institution, nursing institution or similar institution, except a state- or
provincial hospital, which are not registered in accordance with any Act.
4. Costs incurred for treatment arising out of an injury or disablement resulting from war,
invasion or civil war except for PMBs.
5. Any expense incurred by a Member or Dependant who has been duly certified as
mentally unsound.
6. Injuries resulting from occupational sport, speed contests and speed trials except for
PMBs.
7. Attempted suicide, wilfully self-inflicted injuries or sickness conditions or Costs
incurred in respect of treatment associated with drug abuse or overdosing, including
Alkogen treatment except for PMBs.
8. Accommodation or lodging fees in convalescent or old age homes, institutions for the
physically or mentally handicapped or similar institutions.
9. Accommodation and treatment in spas and resorts for health, slimming, chiropractic,
homeopathic or other similar purposes.
10.Accommodation in a private room of a hospital unless prescribed by a medical
practitioner.
11.The cost of holidays for recuperative purposes, whether deemed medically necessary
or not.
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34
12.Examinations for insurance, school camp, visa, employment or similar purposes.
13.Travelling costs incurred by Members or their Dependants
14.Examinations, consultations, treatment, operations and procedures relating to:
14.1.1Obesity;
14.1.2Cosmetic purposes;
14.1.3Bio kinetics;
14.1.4Bio stress assessments;
14.1.5Colonic irrigations;
14.1.6Reversals of sterilisations;
14.1.7Reversals of vasectomies;
14.1.8Acupuncture;
14.2 Laser assisted functional reconstruction of palate and uvula, including follow
up procedures;
14.3 Sclerotherapy of varicose veins;
14.4 Gastroplasty;
14.5 EBCT – Computed Tomography Coronary and heart;
14.6 DNA testing; and
14.7 Harvesting of donor organs (if the donor is not a Beneficiary of the Scheme)
14.8 IQ tests and learning problems.
15.In respect of the Prescribed Minimum Benefit Code 902M: Infertility, the following
services are excluded:
15.1 Assisted Reproductive Technology (ART) techniques, including In Vitro
Fertilisation (IVF);
15.2 Gamete Intrafallopian Tube Transfer (GIFT);
15.3 Zygote Intrafallopian Tube Transfer (ZIFT); and
15.4 Intracytoplasmic Sperm Injection (ICSI).
16.Charges for the following:
16.1 Appointments not kept;
16.2 Telephonic consultations with medical practitioners;
16.3 Emergency unit fees, except for consultations leading to hospitalisation or
emergencies;
16.4 Ante- and post-natal exercise classes;
16.5 Mother craft; and
16.6 Breast-feeding instructions
16.7 Water births
17.Purchase or hire of the following equipment:
17.1 APS therapy machines; or similar devices
17.2 Blood pressure monitors;
17.3 Kidney belts;
17.4 Medic alert bands;
17.5 Mattresses, including Numbis mattresses;
17.6 Peak flow meters; and
17.7 Waterbeds.
17.8 Humidifiers
17.9 Bedpans
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MEMBERGUIDE 2008
17.10 Special beds or chairs
17.11 Cushions
17.12 Commodes
17.13 Sheepskin
17.14 Waterproof sheets
17.15 Health shoes eg Green Cross
18.The purchase of:
18.1 Medicines that are not prescribed on a written prescription of a person
authorised by the Act to do so;
18.2 Mouth protectors, gold inlays, devices and materials such as floss,
toothbrushes and toothpaste;
18.3 Sun screening and tanning agents;
18.4 Sunglasses; lens tinting in access of 35% and spectacle cases;
18.5 Soaps, shampoos and other topical applications, medicated or otherwise;
18.6 Household remedies or preparations of the type advertised to the public;
18.7 Slimming preparations, appetite suppressants, food supplements and patent
foods, including baby foods;
18.8 Growth hormones;
18.9 Synvisc injections;
18.10 Vitamins without a “nappi” code; and
18.11 Other supplements.
19.The following will be subject to the approval of the Clinical committee appointed
by the Board, only for members on the Platinum Option. The Approval of all these
products will be subject to the normal chronic benefits. These products will however
be subject to the normal chronic co-payments..
19.1 Venofer
19.2 Infliximab
19.3 Botox injections
19.4 Immunoglobulin
19.5 Interferon
19.6 Eprex
20.Charges for repairs of Medical Appliances.
21.In the case of contact lenses, the cost of solution kits, as well as the fee associated
with fitting and adjustments.
22 General dental benefit exclusions
22.1 Oral hygiene instructions
22.2 Nutritional and tobacco counselling
22.3 Caries susceptibility and microbiological tests
22.4 Electrognathographic recordings and other such electronic analyses
22.5 Fissure sealants on patients older than 16 years
22.6 Root canal treatment on third molars (wisdom teeth) and primary teeth
22.7 Pulp capping (direct and indirect)
22.8 Polishing of restorations
22.9 Ozone therapy
22.10 Metal base to full dentures, including the laboratory cost
MEMBERGUIDE 2008
36
22.11
22.12
22.13
22.14
22.15
22.16
22.17
22.18
22.19
22.20
22.21
22.22
22.23
22.24
22.25
22.26
22.27
22.28
22.29
22.30
22.31
22.32
Soft base to new dentures
Diagnostic dentures
Provisional crowns
Laboratory cost of provisional and emergency crowns
Resin bonding for restorations
Dental bleaching and porcelain veneers
Metal, porcelain or resin inlays except where such inlays form part of a bridge
Crowns on third molars (wisdom teeth)
Laboratory fabricated crowns on primary teeth
Fixed prosthodontics used to repair occlusal wear
Gingivectomy
Periodontal flap surgery and tissue grafting
Perio Chip
Apisectomies in hospital
Orthodontic re-treatment
Lingual orthodontics
Orthognathic (jaw correction) surgery and the related hospital cost
Hospitalisation for dental implantology
Sinus lifts
Bone augmentations
Bone and other tissue regeneration procedures
Dolder bars and associated abutments on implants (including the laboratory
cost)
22.33 Laboratory costs, where the associated dental treatment is not covered
22.34 Laboratory cost associated with mouth guards (including material cost)
22.35 Snoring appliances
22.36 High impact acrylic
22.37 Cost of Mineral Trioxide
22.38 Cost of prescribed toothpastes, mouthwashes(e.g. Corsodyl) and ointments
22.39 Cost of gold, precious metal, semi-precious metal and platinum foil
22.40 Cost of invisible retainer material
22.41 Cost of bone regeneration material
23.Exclusions and limitation for KeyCap Option
With due regard the statutory requirements regarding the Prescribed Minimum
Benefits, and the services specifically excluded in Annexure B, the DSP shall not be
obliged to provide any of the following services or Benefits as part of the KeyCap.
23.1. The treatment of medical conditions or injuries sustained by a Member or his
registered Dependant(s) not included in the KeyCap.
23.2. All services not obtained through a service provider designated as such by
the DSP, or referrals not pre-authorised, or not provided in terms of the DSP
protocol, subject to Annexure B, Paragraph A.
23.3. All surgical procedures or treatment for cosmetic purposes and/or
reconstructive surgery. The DSP’s Medical Advisory Committee shall have
the sole discretion to determine whether a particular surgical procedure or
treatment is cosmetic in nature and as such excluded, subject to the PMB’s.
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MEMBERGUIDE 2008
23.4. Health care services related to obesity and related complications, portwine
stains, otoplasty for bat ears, keloid scars, hair removal, blepharoplasties
(eyelid surgery), nasal reconstruction (including septpoplasties, osteotomies
and nasal tip surgery), breast reductions and breast reconstructions.
23.5. Recuperative treatment of any nature.
23.6. Health care services relating to willful self-inflicted illness or injury, except for
PMB’s.
23.7. Except for Benefits payable in respect of the PMBs, health care services
required as a consequence of:
23.7.1 injuries sustained resulting from participation in willful and material
Actions or omission in contravention of any statutory or common law
provision;
23.7.2 participation in acts of war;
23.7.3 participation in a terrorist activity;
23.7.4 injuries or medical conditions resulting from riot, civil commotion,
rebellion or insurrection;
23.7.5 experimental, unproven or unregistered treatment;
23.7.6 injury or illness that occurred beyond the borders of the Republic of
South Africa;
23.7.7 any complication that may arise from any exclusion listed in the
Annexure.
23.8. Frail care treatment.
23.9. Surgery or treatments not medically indicated.
23.10.Health care services required during any compulsory waiting period, except
for PMBs.
23.11. Medical examinations initiated by Employers.
23.12.Non-medically essential items or treatments.
23.13.Treatment for injuries where another party is responsible for payment (e.g.
workman’s compensation/IOD’s – Injury on duty reports).
The Member is however entitled to such Benefits as would have applied
provided that on receipt of payment in respect of medical expenses the
Member will reimburse the Scheme any money paid out by the Scheme in
respect of this benefit.
23.15.Dental extractions for non-medical purposes.
23.16.The provision of gold inlays in dentures.
23.17.The provision of medical, surgical or other appliances, unless a PMB or
specifically stated otherwise.
23.18.The supply of:
23.18.1 applicators, toiletries and beauty preparations;
23.18.2 cotton wool and other consumable items;
23.18.3 patented foods, including baby foods;
23.18.4 tonics, slimming preparations or medicines as advertised to the public;
23.18.5 household and biochemical remedies;
23.18.6 steroids;
23.18.7 sunscreen agents;
23.18.8 Roaccutane and Retin A, or any skin lightening treatments.
MEMBERGUIDE 2008
38
30. FRAUD LINE
The cost of medical fraud in South Africa is estimated at billions each year. If you know
of any service provider or member who is making dishonest claims against your medical
scheme, you can report them at 0860 673 000.
The fraud line is available during office hours and for your convenience you will only be
responsible for local call costs, while the difference will be paid by the scheme.
All calls are treated confidentially.
31. THE INTERNET www.keyhealthmedical.co.za
KeyHealth’s website on the worldwide web is an interesting, interactive gathering place for
a KeyHealth member, service provider, broker and the Scheme.
Easy steps to register as an internet user
Take the following steps to register on the website as a user:
1. Click on the “Register a password” link (on the left-hand side of the webpage);
2. Fill in the necessary information: “number” is your member number, “password” is
one chosen by you and may consist of between 6 and 8 alphanumerical characters.
It is important to remember whether you have used capital or lower case letters for
your password, as the password is case sensitive.
3. Click on the “Submit” button. The information will be submitted to the database.
4. A letter will appear on your screen. Print out this letter, sign it and fax back to the
number provided.
5. Your password will be activated on the system. You will be notified of activation via
e-mail.
Online enquiries
A member can view his/her claims history and personal information by clicking on the
Online Enquiries button on the left-hand side of the webpage. To gain access, enter your
membership number and password and you will be logged in. The “Summary” information
page is displayed.
The following information can be viewed:
“Summary” - the last 5 claims, the last statements of the last 2 months and the contributions
of the last 2 months are displayed.
“Details” – this page contains all your personal information. Click on “Change details” to
update your personal information and submit.
“Claims” – all claims submitted are displayed
“Benefits” – benefits used and available are displayed for each service category
“Graphs” – a pie chart that breaks down the claims associated with your benefits
“Statements” – a view of your statements and the claims involved
“Contributions” – a view of your contribution details
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MEMBERGUIDE 2008
“Waiting periods” – an indication of a waiting period that applies to you
“Correspondence” – a view of all the correspondence exchanged between yourself and
the scheme
“Enquiries” – a view of all enquiries logged
“Claims Calculator” – it allows the member to check what would happen to a claim if
submitted for assessing
“Providers” – use this option to find the nearest service provider in your area
“SMS” – allows you to send a cellphone message from the web
“Cases” – a screen where all your chronic medication and hospital cases are
documented
“Medicine Search” – it allows you to search for medication and it will supply you with the
price, pack size and nappi code of the product.
“Health Info” – gives more information on chronic conditions, lifestyle conditions or clinical
reference.
Forgot your password
In the event of forgetting your password, click on “Online enquiries”. Click on the “Forgotten
your password” option. Enter your membership number at “Login” and select the “member”
button and submit.
You will immediately be notified via sms and e-mail of your password.
32. E-MAIL FACILITY
KeyHealth has always believed that access to information strengthens the relationship
with our members.
Webmail is a simple e-mail based interface for members to get access to their medical aid
information, without having to phone the Client Service Centre or log onto the web.
The member can activate a webmail by e-mailing KeyHealth at webmail@keyhealthmedical.
co.za. No details are required in the subject field or the body of the mail.
The e-mail address of the member will be authenticated against the e-mail address loaded
into the system. If your e-mail addess is not loaded onto the system or if there is more than
one member with the same e-mail address you will receive a response, informing you that
we are unable to authenticate this e-mail address and are therefore unable to generate
the webmail.
If your e-mail address is authenticated, the system then e-mails you a complete “package”
of information. The package includes:
• Membership details
• Case History
• Claims History
• Benefits
• Contributions
MEMBERGUIDE 2008
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• Claims advice
Should you require further information, please contact the KeyHealth Client Service Centre
at 0860 671 050.
33. SMS FACILITY
Members have access to useful information 24 hours a day by sending a SMS. The
options are as follows:
Send a SMS with the letter B as the message and you will receive a SMS with your current
benefits available.
Send a SMS with the letter C as the message and you will receive a SMS with your claims.
[last statement]
Send a SMS with the letter D as the message and you will receive a SMS with your
membership details.
Send a SMS with the letter IC and the relevant ICD- 0 code as the message and you will
receive a SMS with the ICD-10 description details.
All members can send a SMS to 31413.
You should receive a reply within minutes, provided your cell number is up to date on
KeyHealth’s system.
Contact the Client Service Centre at 0860 671 050 to update your personal details.
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MEMBERGUIDE 2008
34. YOUR CLAIMS ADVICE
MEMBERGUIDE 2008
42
35. IMPORTANT CONTACT INFORMATION
Client Service Centre
0860 671 050
Netcare 911
082 911
Fax:
(012) 673 2800
Hospital pre-authorisation
0860 671 060
Pregnancy management programme
0860 671 060
Oncology management programme
0860 671 060
Fax:
0866 040 652/51
Dental pre-authorisation
0860 104 926
Fax:
(021) 671 4424
Lifesense disease management
0860 506 080
Crisis line
082 911
Chronic medication approval
0800 132 345 (Doctors)
(SwiftAuth Online)
(011) 770 6200 (Members)
Emergency numbers for
0860 671 060
After-hours hospital admissions
Fraud line
0860 673 000
PrimeCure (DSP for KeyCap)
0861 665 665
Designated service providers for Chronic medication:
Atlas Pharmacy (Durban)
(031) 242 3100
Atlas Pharmacy (Pietermaritzburg)
(033) 394 6601
Chronicare
0860 102 304
Medipost
(012) 426 4075
Umhlatuze Pharmacy
(035) 789 0106
Postal addres
Head Office (Centurion)
P.O. Box 14145
LYTTELTON
0140
INTERNET
www.keyhealthmedical.co.za
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MEMBERGUIDE 2008