Prescribed Minimum Benefits

Diagnosis codes from the International Classification of Diseases, 10th Revision (ICD10) are used to identify a medical condition as a Prescribed Minimum Benefit (PMB).  When a condition is defined as a PMB it means that, if you have medical scheme cover, then, with some provisos, your scheme is required to pay for the diagnosis and treatment of the condition in full.  This payment must not be made from your savings account, so check where the payment is coming from within your scheme benefits.

The most important thing you need to do to access PMB benefits is to call your scheme and find out if they use Designated Service Providers (DSPs) and what you need to do to ensure that your claims for this condition are correctly paid.

The PMBs are made up of:

  • Any emergency medical condition
  • 270 diagnoses (based on a diagnosis code) and,
  • 25 chronic conditions (also based on a diagnosis code)

The 270 diagnoses are linked to treatments and these, together, are known as diagnosis treatment pairs (or DTPs).

The provisos are important.

Firstly, if there is any dispute about what type of treatment the medical scheme has to pay for, then the treatment standards applied in government clinics and hospitals will be taken as the standard.  The medical scheme is not required to pay for anything above this standard.

Secondly the medical scheme may contract with some providers (doctors, hospitals, etc.) – known as Designated Service Providers (DSPs) – and require that you use these service providers if you want the account to be paid in full by the medical scheme.  If you use a provider that is not a DSP you will have to make some or all of the payment yourself.  The DSP must be within a reasonable distance of your work or home and they must be able to provide the services you need.  If they are too far from your home, or can’t provide the services you need, then the medical scheme must pay for the services at a non-DSP provider.  Also, in an emergency, you need not go to a DSP, and the medical scheme must pay in full.

Helping to get your claims paid