UNPROFESSIONAL EXPLAINED DECISION

REFERENCE NUMBER : ********** 542 MY MOTHERS DOCTOR HAVE REQUESTED PMB TREATMENT FOR THE PATIENT. YET DISCOVERY HAS ONLY APPROVED CONSULTATIONS AND NO DRUGS TO MANAGE THE CONDITION. YET THE BE PMB GUIDELINE AS PER CMS REGULATIONS INDICATES THAT MEDICAL MANAGEMENT IS AN APPROPRIATE LINE OF TREAT MENT FOR HER CONDITION. WAS THE TREATMENT NOT APPROVED BECAUSE THERE ARE FORMULA ALTERNATIVES OR WHAT THE PROPER INFORMATION WAS NOT CONVEYED YET AGAIN I FIND THAT BIPOLAR HAS A DRUG LIST AND IS TREATED WITH DRUGS YET HERE MY MUM IS SUFFERING FROM A SISTER CONDITION UNIPOLAR THAT DISPLAYS THE SAME SET OF SYMPTOMS AND HAS THE SAME HARMFUL EFFECTS HOW DOES DISCOVERY WANT HER TO RECOVER WHILST ONLY ALLOWING HALF TREATMENT MEASURES.SECONDLY THEY HAVE A APPROVED 10 CONSULTATION FROM 1 JAN TO 31 DEC YET SHE WAS ONLY DIAGNOSED IN AUGUST BUT HER PREVIOUS PMB CONDITIONS WERE APPROVED FROM THE DATE OF DIAGNOSIS TO THE SAME DATE THE FOLLOWING YEAR LIKE HER PEPTIC ULCER AND PULMONARY EMBOLISM. WHY WAS THIS CONDITION ONLY APPROVED TILL DEC I WANT TO KNOW IF WE HAVE TO RESUBMIT A NEW APPLICATION NEXT YEAR. THAT WILL COST THE MEMBER AGAIN MONEY CAUSE THE DOCTOR CHARGES +-R 500 FOR THE SIGNATURE THIS THAT DISCOVERY INFORMED US WILL PAY BUT THE CLAIM HAS BEEN REJECTED PLEASE LOOK INTO THIS CLAIM AS WELL. THE FACT OF THE MATTER IS THAT WHY ARE DRUGS SUCH AS ALZAM AND YALATE PRESCRIBED WHEN MEDICAL AID ASSUMES WITH THERE HIGH KNOWLEDGE THAT THEY DO NOT HAVE TO APPROVE THIS DRUGS. YET THEY SENT US TO THE DOCTORS WHO PRESCRIBES THEM. LASTLY RAGARDING THE PREVIOUS POST WITH NETWORK DENTIST I WOULD LIKE TO KNOW IF THE DOCTOR PATEL AN C VAN DER MERWE ARE ON OR OF THE NETWORK AN THE PRACTICES THEM SELVES DO NOT KNOW ASWELL AS DR BOTES IN ODENDAALSRUS IS HE ON THE PREMIER PLUS NETWORK OR NOT.

DISCOVERY CANNOT LET PATIENTS DO THERE DIRTY WORK OF GOING AROUND AND FINDING OUT IF THE DOCTOR IS ON THE NETWORK OR NOT. DO IT YOURSELF.

CONCLUDING I WOULD LIKE TO KNOW IF AN OUT OF NETWORK DOCTOR IS ABLE TO REFER A PATIENT TO PATHOLOGY AND RADIOLOGY FOR FURTHER TEST OR NOT AS HE DEEMS FIT.

URGENT

PLEASE APPROVE MEDICATION FOR THE PMB CONDITION