How do I use my plan at a hospital?
If you have hospital cover on your health insurance plan then you can use your benefits at any private hospital in South Africa. Here is how it works.
What is Authorisation?
Authorisation is the process where the insurer and the hospital work out whether the treatment you need is covered under your benefits and for how much.
The product Administrator, EssentialMED, will give the hospital approval in the form of a Guarantee of Payment. The Guarantee of Payment tells the hospital how much money is available for your claim, according to your benefits.
Africa Assist handles hospital authorisations for your EssentialMED policy.
What if the hospital doesn't recognise Episodic or EssentialMED?
They don't need to. Health Insurance doesn't work like a Medical Aid.
For Medical Aids, the hospital needs to recognise the scheme because they contract directly with the scheme to determine rates and tariffs.
With a Health Insurance, the hospital simply contacts Africa Assist to get the authorisation with a Guarantee of Payment which tells the hospital exactly how much money is available to be paid for the claim.
So they don't need to have Episodic or EssentialMED loaded on their systems. This is why Health Insurance can work with any private or public hospital.
What if the hospital wants a deposit or payment upfront?
The hospital really just wants to know that they will get paid for their service. The Guarantee of Payment tells the hospital that this will happen.
However, some hospitals insist on an upfront payment or deposit. In these extreme cases, the insurer can make an upfront payment to put them at ease.
How to get Authorisation
You can do it yourself or the hospital can do it with you. Simply call Africa Assist on 0861 911 011 and identify yourself as having an EssentialMED policy (remember, your Episodic plan is an EssentialMED plan).
They will guide you through the rest of the process.
You can also send an email to info@essentialmed.co.za or claims@essentialmed.co.za.
