Your medical emergency first-aid kit

● All medical emergencies are prescribed minimum benefits that medical schemes are obliged by law to cover in full, regardless of what the healthcare provider charges to treat you.

● Medical schemes are allowed to name certain facilities or doctors as designated service providers (DSP) and insist you use them to get full cover for PMB conditions. But in an emergency, if you use a non-DSP facility or doctor, you will be regarded as having involuntarily sought healthcare services and your scheme must still pay.

● No PMB claims can be paid from your medical savings account.

● If your scheme refuses to pay a claim, stating it has no proof that it was a medical emergency, you need to get the doctor to provide clinical motivation to the scheme.

● Providers who perform diagnostic tests, such as X-rays or blood tests, won’t put an ICD-10 diagnostic code on your claim that identifies your condition. Instead they use Z-codes for yet-to-be-diagnosed conditions. To get these claims paid as PMBs you may have to ask the doctor to send a request to the radiologist or pathologist to recode the claim and resubmit it to your scheme.

● A fractured limb may or may not qualify as a PMB.