GB
Garth B
1 reviews | Active since Mar 2015
18 Mar 2015, 09:09
Authorisation of Arthroscopy
I have been a member of Transmed Medical Scheme for 35+ Years.<br> <br> I went to the hospital on Monday, as the pain is so unbearable, that I am finding it difficult to walk, but being refused an authorisation number from Transmed, as it is not a PMB.<br> <br> Even after X-rays and a motivation from the Dr, Transmed still refuses to pay the procedure.<br> <br> Why am I paying just over R6000 for 2 members, if we do not really get any benefits from Transmed???<br> <br>
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Transmed's replyOfficial
23 Mar 2015, 08:47Hello GABrits,
The Private Network plan only cover Prescribed Minimum Benefits (PMB). The authorisation was declined because your pre-authorisation request was for a non-PMB related condition (pain in joint, lower leg). The case with the necessary motivation letter was referred to the Medical Advisor for review. The Medical Advisor confirmed that the diagnosis is non-PMB related and the 'denied status' should be maintained.
Due to the member demography and high claiming patterns from members on the Private Network plan, the Fund was forced to change the medical cover effective 1 October 2012 to only cover for PMB related conditions. Should the Fund have continued to fund non-PMB related conditions the contributions would have been much higher.
Kind regards
The Transmed Team
The Private Network plan only cover Prescribed Minimum Benefits (PMB). The authorisation was declined because your pre-authorisation request was for a non-PMB related condition (pain in joint, lower leg). The case with the necessary motivation letter was referred to the Medical Advisor for review. The Medical Advisor confirmed that the diagnosis is non-PMB related and the 'denied status' should be maintained.
Due to the member demography and high claiming patterns from members on the Private Network plan, the Fund was forced to change the medical cover effective 1 October 2012 to only cover for PMB related conditions. Should the Fund have continued to fund non-PMB related conditions the contributions would have been much higher.
Kind regards
The Transmed Team
Transmed's reply23 Mar 2015, 08:47
Official
Hello GABrits,
The Private Network plan only cover Prescribed Minimum Benefits (PMB). The authorisation was declined because your pre-authorisation request was for a non-PMB related condition (pain in joint, lower leg). The case with the necessary motivation letter was referred to the Medical Advisor for review. The Medical Advisor confirmed that the diagnosis is non-PMB related and the 'denied status' should be maintained.
Due to the member demography and high claiming patterns from members on the Private Network plan, the Fund was forced to change the medical cover effective 1 October 2012 to only cover for PMB related conditions. Should the Fund have continued to fund non-PMB related conditions the contributions would have been much higher.
Kind regards
The Transmed Team
The Private Network plan only cover Prescribed Minimum Benefits (PMB). The authorisation was declined because your pre-authorisation request was for a non-PMB related condition (pain in joint, lower leg). The case with the necessary motivation letter was referred to the Medical Advisor for review. The Medical Advisor confirmed that the diagnosis is non-PMB related and the 'denied status' should be maintained.
Due to the member demography and high claiming patterns from members on the Private Network plan, the Fund was forced to change the medical cover effective 1 October 2012 to only cover for PMB related conditions. Should the Fund have continued to fund non-PMB related conditions the contributions would have been much higher.
Kind regards
The Transmed Team