Members on the Managed Care Plan must authorise planned hospital admissions. Most hospitals require benefit confirmation before admission, and completing Anglo Medical Scheme's simple authorisation procedure will prevent any delay at the time of admission. Call us on 0860 222 633 for authorisation.
General hospital services, radiology and pathology is unlimited and paid at 100% of the Scheme Reimbursement Rate (SRR). The Top-Up rate (previously GAP) pays up to a maximum of 230% of the SRR for specialist services in hospital excluding pathology, radiology, allied healthcare services and GPs performing specialist services (230% = 100% SRR + additional 130% of SRR).
Hospital services including allied healthcare services (as determined by the Scheme), day cases, blood transfusions, radiology, pathology, professional services and 7-day supply of to-take-out medication.
You will not have to pay for any claims for the treatment of Prescribed Minimum Benefit conditions except for specific Scheme exclusions.
A co-payment of a minimum of R390 per day applies, up to a maximum of R1 170 for a hospital stay for non-Prescribed Minimum Benefit conditions.
Members have access to step-down facilities and private nursing instead of hospitalisation, where intermediate care is necessary, subject to protocols. Contact the Call Centre on 0860 222 633 for authorisation.
Anglo Medical Scheme participates in our Administrator’s network of orthotists and prosthetists, members need to use one of the participating Designated Service Providers to avoid co-payments.
Internal surgical prostheses are subject to an annual limit of R133 900 per beneficiary.
Procedures in doctors’ rooms
Procedures performed by GPs in rooms instead of hospital will be paid by the Scheme at the SRR, subject to authorisation, Scheme protocols and a defined list of procedures.
Specialist procedures performed in rooms instead of hospital will be paid by the Scheme at the Top-Up rate up to 230% of SRR, subject to authorisation, Scheme protocols and a defined list of procedures.
Emergency Hospital Admissions
You do not require an authorisation for emergency admissions at the time of the emergency. However, please contact Anglo Medical Scheme on 0860 222 633 within 48 hours of the admission. Once the Scheme is aware that you have been hospitalised, more effective management of the case is possible.
Psychiatric admissions to hospitals are limited to 21 days.