Going to see a healthcare provider

Overview

Cover for any in-hospital and several other high cost treatments and care must be confirmed by the Scheme prior to the member actually undergoing the treatment.

Remember to phone 0860 103 933 to confirm (preauthorise) all in-hospital benefits, as well as those for MRI or CT scans, endoscopic procedures, oncology, dentistry done in hospital and others. 

For all planned procedures or treatment, you must call us at least 48 hours before you are planning to undergo the medical care.

Emergency/Casualty

Even if your chosen Benefit Option has designated specific hospitals as the providers that should be used to ensure cover in full, we will cover your emergency admission in full as a Prescribed Minimum Benefit in any hospital you are admitted to.

You, the hospital, or one of your family members must inform the Scheme of your admission as soon as possible after the emergency – and at least within 48-hours thereof.

In the case of LA KeyPlus or LA Focus members, where only certain hospitals may be used for planned procedures and non-emergency PMBs, the Scheme will not transfer members to another hospital, except where the required medical treatment is not available from the non-network hospital to which the member was admitted.

Moving a member from a non-network hospital to one that is in the network, other than in the above situation, would only be done in consultation with the member and the treating doctor, where the member is out of danger but is likely to remain hospitalised for a lengthy period for monitoring purposes, or to receive ongoing treatment.

If you choose to stay in the non-DSP hospital (without further clinical motivation), we will pay your claims in terms of the specific rules of your chosen benefit option and you may have to make a co-payment or self-fund the shortfall.

Designated Service Provider (DSP)

When you use the services of a Designated Service Provider (DSP), all claims, including Prescribed Minimum Benefits, are paid in full. This means you will not have to make out-of-pocket payments when using the services of these providers.

These Designated Service Providers are specific providers of healthcare services, for example General Practitioners and Specialists, who have agreed to provide services to the LA Health members according to certain agreed rules. The Scheme pays these providers directly.

In certain instances, you must use the services of the designated service providers.  If you do not use these services, you may have to pay deductibles or make co-payments.

In certain instances, you will not have to pay co-payments or deductibles 

The Scheme will still pay the Prescribed Minimum Benefit claims in full if you have involuntarily obtained the services from a provider other than a designated service provider, if:

  • it was an emergency, for hospital admissions
  • the service was not available from the designated service provider or would not have been provided without unreasonable delay; or
  • there was no designated service provider within a reasonable distance from your place of business or residence.

The Scheme’s designated service providers for the diagnosis, treatment and care costs (which may include medicine) for Prescribed Minimum Benefit (PMB) conditions are:

Specialist Services

The Premier Rate Specialist Network

General Practitioners’ Services

The Discovery GP Network

Chronic Medicine

Any pharmacy willing to charge dispensing fees at the Scheme’s Medicine Rate.

Drug and alcohol rehabilitation

SANCA, Nishtara or RAMOT

Renal care, including dialysis

National Renal Care

Oxygen rental

VitalAire

It is likely that the Scheme will contract with, and appoint more designated service providers, particularly provider networks, in its ongoing efforts to control and reduce costs for members.

Other Designated Service Providers to the Scheme

PET Scans

Centres of Excellence identified by the Scheme

Stem cell transplants

Centres of Excellence identified by the Scheme

Where the Scheme has appointed a Designated Service Provider (such as these listed above), non-emergency PMBs will only be paid in full if the services are obtained at the DSP.

Click here for your In-hospital guide.

Planned Operations

If you and your doctor are planning an admission, you must confirm benefits (preauthorise) before you are admitted to hospital. To authorise your hospital admission, please phone us at 0860 103 933 at least 48-hours before you plan to go to the hospital. If you are admitted to hospital outside of business hours, please call us as soon as you can thereafter.

You need to give us these details:

  • When you will be admitted to hospital and how long you’ll stay
  • Your treating doctor’s name, practice number and phone number
  • Your diagnosis (ask your doctor for the ICD-10 diagnosis code)
  • The procedure name and code, if available (ask your doctor for the CPT4 or RPL procedure code)

You must preauthorise at least 48 hours before your planned hospital admission, except in emergencies. If you don’t, we will only pay 70% of the hospital cover to which you’re normally entitled. You’ll have to pay the remaining 30% of the costs.

LA KeyPlus members must use one of these day clinic facilities or hospitals for any planned in-hospital care.

LA Focus members must use one of these day clinic facilities or hospitals for any planned in-hospital care. 

Prescribed Medicine

Prescribed medicine is normally taken when your condition is acute and will clear up within a short space of time, such as when you have influenza.

Over-the-counter medicine (OTC)

Schedule 0 - 2 medicine, whether prescribed or not, is also known as over-the-counter medicine. We will only pay for medicine bought over-the-counter if you have available funds in your Medical Savings Account.

We will only pay for acute or over-the-counter medicine if:

  • It is prescribed by a registered healthcare provider with a valid practice number, in the case of acute medicine.
  • You get the medicine from a registered healthcare provider with a valid practice number;
  • The claim displays a valid ICD-10 and medicine dispensing code.
How prescribed medicine is paid out on the LA Health Benefit options

Benefit Option

Cover for Prescribed Medicine

LA Comprehensive

Paid at 100% of the LA Health Medicine Rate from the Medical Savings Account and the Above Threshold Benefit, subject to available funds and the applicable limits for medication that is on the Scheme's list of Preferred medicine. Cover is at 90% of the LA Health Medicine Rate if medication is used that is not on the Preferred list of medication. Please refer to your benefit brochure for the applicable limits.

LA Core

Paid at 100% of the LA Health Medicine Rate from the Medical Savings Account and the Extended Day-to-Day Benefit, subject to available funds and limits. Cover is at 90% of the LA Health Medicine Rate if medication is used that is not on the Preferred list of medication.

LA Active

Paid at 100% of the LA Health Medicine Rate from the Medical Savings Account and the Extended Day-to-Day Benefit, subject to available funds and limits. Cover is at 90% of the LA Health Medicine Rate if medication is used that is not on the Preferred list of medication.

LA Focus

Paid at 100% of the LA Health Medicine Rate from the Medical Savings Account, subject to available funds and limits. Cover is at 90% of the LA Health Medicine Rate if medication is used that is not on the Preferred list of medication.

LA KeyPlus

Only covers acute and non-PMB chronic conditions subject to a formulary when the medicine is prescribed by the member’s chosen General Practitioner (doctor) working in the KeyCare provider network.

General Practitioners

A general practitioner or GP is a medical practitioner who provides primary care and specialises in family medicine. A general practitioner treats acute and chronic illnesses and provides preventive care and health education. They have particular skills in treating people with multiple health issues.

On the LA Focus, LA Active, LA Core and LA Comprehensive Options any General Practitioner who participates in the Discovery GP Network is the Designated Service Provider for all GP visits. There are more than 3 000 GPs in this ‘willing provider network’ and you will be able to see whether your GP is participating in this network, find out more by calling 0860 103 933.

If you use one of these providers, you will not be liable for any co-payments as claims would be paid at the Scheme Rate, directly to the Network provider. If applicable, the specific limits in your Benefit Option will apply. If you do not use the services of a Network GP, your claim will be paid at the Scheme Rate only and we will make the payment to you. You will have to settle the full account with the GP.

On the LA KeyPlus Option, any GP in the KeyCare GP Network is the Scheme’s Designated Service Provider. If you do not use the services of one of the KeyCare GPs for in- and out-of-hospital consultations, benefits will be limited or you will have to pay for the treatment. You will be able to see whether your GP is participating in this network, find out more by calling 0860 103 933.

Cover for GPs is dependent on the benefits offered by your Option.

 

In hospital

Out of hospital

LA Comprehensive

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network providers will be covered up to the Scheme Rate.

Consultations are covered in full from available funds in MSA or Above Threshold benefit at the Scheme’s network providers.

Consultations at non-network providers will be covered up to the Scheme Rate

LA Core

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network providers will be covered up to the Scheme Rate.

Consultations are covered in full from available funds in MSA or Extended Day-to-Day Benefit at the Scheme’s network providers.

Consultations at non-network providers will be covered up to the Scheme Rate

LA Active

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network providers will be covered up to the Scheme Rate.

Consultations are covered in full from available funds in MSA or Extended Day-to-Day Benefit at the Scheme’s network providers.

Consultations at non-network providers will be covered up to the Scheme Rate

LA Focus

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network providers are covered up to 100% of the Scheme Rate.

Consultations are covered in full from available funds in MSA at the Scheme’s network providers.

Consultations at non-network providers will be covered up to the Scheme Rate

LA KeyPlus

Consultations are covered in full if a KeyCare GP is used

Consultations at non-KeyCare GPs will be for the members own account

No overall limit for consultations - provided that the member’s chosen GP within the Scheme’s DSP network or KeyCare network is used.

For members travelling or on holiday - Four (4) out-of-network GP visits are allowed per person per year

Specialists

specialty in medicine is a branch of medical science.  After completing medical school, physicians or surgeons usually further their medical education in a specific specialty of medicine by completing a multiple year residency. Medical practitioners who engage in a medical specialty are known as medical specialists.

Any participating specialist in the Discovery Premier Rate Network is one of the Scheme’s DSP specialists on the LA Focus, LA Active, LA Core and LA Comprehensive Options.  If you make use of their services for in- or out-of-hospital care, you will not have to make any ‘above the Scheme Rate’ co-payments as the provider will only charge at the Scheme Rate. LA Health will pay these claims in full, directly to the Premier Rate Specialist.

You can make sure that you are using a Network Specialist by following this link or find out more by calling 0860 103 933.

If you do not use the services of a network specialist, you may have co-payments.  We will pay these claims at the Scheme Rate only and always pay you directly if the amount claimed is above the Scheme Rate. You will have to settle the claim in full.

On the LA KeyPlus Option, the Scheme’s Designated Service Provider Specialists are Specialists on the KeyCare Specialist network.  If the services of any other Specialist are used in-hospital, you will have to pay for the services from your own pocket.

Out-of-hospital Specialist services on the LA KeyPlus Option are only available on referral from the member’s chosen KeyCare GP.  If the member bypasses this process and consults a Specialist without referral from a network GP, no benefit will be payable by the Scheme.

Cover for Specialists, and the specific limits that may apply, is dependent on your Benefit Option.

 

In hospital

Out of hospital

LA Comprehensive

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network specialists will be covered up to the Scheme Rate.

Consultations are covered in full from available funds in MSA or Above Threshold benefit at the Scheme’s network providers.  

Consultations at non-network specialists will be covered up to the Scheme Rate.

LA Core

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network specialists will be covered up to the Scheme Rate.

Consultations are covered in full from available funds in MSA or Extended Day-to-Day Benefit at the Scheme’s network providers.  

Consultations at non-network specialists will be covered up to the Scheme Rate.

LA Active

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network specialists will be covered up to the Scheme Rate.

Consultations are covered in full from available funds in MSA or Extended Day-to-Day Benefit at the Scheme’s network providers.  

Consultations at non-network specialists will be covered up to the Scheme Rate.

LA Focus

Consultations are covered in full at the Scheme’s network providers.

Consultations at non-network specialists are covered up to 100% of the Scheme Rate.

Consultations are covered in full from available funds in MSA at the Scheme’s network providers.

Consultations at non-network specialist will be covered up to the Scheme Rate.

LA KeyPlus

Consultations are covered in full at a specialist within the KeyCare Hospital Network.

Consultations at non-network specialists will be for the member's own account.

To obtain the services of a Specialist out-of-hospital, members must be referred by one of the KeyCare GPs.

If the necessary referral process is used, the benefit is paid in full subject to a limit of R4 400 per person for the year.

Dentists

Dentistry is the evaluation, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body.

All dentistry performed in hospital must be authorised (with additional network provider approval on LA Focus)

The Scheme provides unlimited benefits for certain major and trauma-related dental procedures.  These procedures are certain severe infections, jaw-joint replacements, cancer-related and certain trauma-related surgery, cleft-lip and palate repairs and are normally performed in-hospital.  These procedures require preauthorisation. 

Cover for dentists is dependent on your Benefit Option.

 

In hospital

Out of hospital

LA Comprehensive

Specialised dentistry

The hospital account will be subject to an upfront amount that is paid from the member’s own pocket. The remainder of the hospital account is paid by the Scheme.
All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid by the Scheme, subject to a joint overall limit per person for specialised dentistry. This limit applies in and out of hospital.

Basic dentistry

The hospital account will be subject to an upfront amount that is paid from the member’s own pocket. The remainder of the hospital account is paid by the Scheme.
All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid from the MSA and the ATB, subject to a joint overall limit per person for basic dentistry. This limit applies in and out of hospital.

Please refer to your benefit brochure for the applicable limit amount and co-payment

Specialised dentistry

Benefits are paid from and limited to funds in MSA and the ATB. All specialised dentistry benefits allocate to, and are subject to, the overall limit for specialised dentistry, per beneficiary for the year.

Basic dentistry

Benefits are paid from and limited to funds in MSA and the ATB. All basic dentistry benefits allocate to, and are subject to, the overall limit for basic dentistry, per beneficiary for the year.

LA Core

Specialised dentistry

The hospital account will be subject to an upfront amount that is paid from the member’s own pocket. The remainder of the hospital account is paid by the Scheme. All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid by the Scheme, subject to a limit per person for specialised dentistry.

Basic dentistry

The hospital account will be subject to an upfront amount that is paid from the member’s own pocket. The remainder of the hospital account is paid by the Scheme All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid from the MSA and the Extended Day-to-Day Benefit.

Please refer to your benefit brochure for limits and further information

Specialised dentistry

Benefits are paid from and limited to funds in MSA and the Extended Day-to-Day benefit. Basic dentistry Benefits are paid from and limited to funds in MSA and the Extended Day-to-Day benefit.

LA Active

Specialised dentistry

The hospital account will be subject to an upfront amount that is paid from the member’s own pocket. The remainder of the hospital account is paid by the Scheme. All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid by the Scheme, subject to a limit per person for specialised dentistry.

Basic dentistry

The hospital account will be subject to a co-payment paid from the member’s own pocket. The remainder of hospital account is paid by the Scheme. All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid from the MSA and the Extended Day-to-Day Benefit.

Please refer to your benefit brochure for limits and further information

Specialised dentistry

Benefits are paid from and limited to funds in MSA and the Extended Day-to-Day benefit.

LA Focus

Specialised dentistry

The hospital account will be subject to an upfront amount that is paid from the member’s own pocket. The remainder of the hospital account is paid by the Scheme. All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid by the Scheme, subject to a limit per person for specialised dentistry.

Basic dentistry

The hospital account will be subject to an upfront amount that is paid from the member’s own pocket. The remainder of the hospital account is paid by the Scheme. All related, non-hospital accounts (for example, for the surgeon and anaesthetist) are paid from the MSA.

Please refer to your benefit brochure for limits and further information

Specialised dentistry

Benefits are paid from and limited to funds in MSA Basic dentistry Benefits are paid from and limited to funds in MSA.

LA KeyPlus

Subject to preauthorisation

Basic dentistry full cover with no overall benefit limit, subject to a list of procedures performed by a dentist in the KeyCare network.

Wellness Programme

Research shows that if you want to improve your health and prevent disease, it can be as easy as making small, sustainable and positive daily lifestyle adjustments.

These adjustments mean being physically active, following a healthy diet, taking preventive measures and making healthy lifestyle choices. By making these choices every day, you significantly improve and maintain wellness – a combination of holistic physical, mental and spiritual wellbeing. 

LA Health members have access to an exciting health and lifestyle programme at an additional cost.  This programme is offered by the Scheme’s Administrator, Discovery Health.

Don’t miss out, call 0860 103 933 to find out how you too can start your journey to a healthier lifestyle.

Other (physiotherapists, etc.)

Allied and alternative healthcare professionals are clinical healthcare professionals other than those practicing medicine, dentistry and nursing. They work in a healthcare team to take care of all aspects of a medical condition.

Cover for Allied and Alternative healthcare professionals is dependent on your Benefit Option.

Some of the services covered by this benefit are:

  • physiotherapy
  • occupational therapy
  • homeopathy
  • audiology
  • psychology
  • chiropody
  • naturopathy, and
  • chiropractors.

 

Benefit

LA Comprehensive

Limited to available funds in the MSA and Above Threshold Benefit.Nurse practitioners will be paid up to a limit per family per year from the available funds in the MSA/ATB

LA Core

Limited to available funds in the MSA

LA Active

LA Focus

LA KeyPlus

No benefit, other than PMB cover

Radiology

Radiology is the medical specialty that deals with the study and application of imaging technology like X-ray and radiation to diagnose and treat disease.

If these services are required as part of your authorised, in-hospital treatment, the Scheme will pay for it from the Major Medical Benefit (MMB). If it’s required out-of-hospital, it will be covered from the applicable Day-to-day benefit, as per your Benefit Option.

 

In hospital

Out of hospital

LA Comprehensive

MRI and CT Scans paid from MMB

LA Core

LA Active

Scan paid from the MMB

The scan will be subject to a co-payment payable from available funds in your MSA. Remainder of the cost paid from MMB

LA Focus

LA KeyPlus

MRI and CT Scans will only be paid if authorised and performed at a KeyCare Network hospital, on referral by a Specialist.

MRI and CT Scans paid from available funds in your Specialist Benefit.

Blood tests (pathology)

When these tests are required as part of your authorised in-hospital treatment, the Scheme will pay for it from your Major Medical Benefit, subject to the Rules for your Benefit Option.

When the tests are performed out-of-hospital, it will be paid for from your Day-to-day benefits and in accordance with the specific rules applicable to your Benefit Option.

Please ask your doctor to use the Discovery Pathology form when he or she requests these tests.

The Discovery Pathology form is designed to:

  • Make doctors aware of the costs associated with different codes
  • Enable doctors to request only the specific tests they deem clinically appropriate
  • Track the use of our form using the unique Discovery Health barcode in the bottom right hand corner
  • Assist doctors to request the pathology codes that are covered on the KeyCare benefit option. These codes are shown on the front of the form

Scopes (endoscopic procedures)

Each Benefit Option offers a different level of cover for endoscopic procedures performed in- or out-of-hospital.  The endoscopies are:

  • gastroscopies,
  • colonoscopies,
  • sigmoidoscopies, and
  • proctoscopies

 

In hospital

Out-of-hospital

LA Comprehensive

Unlimited and paid from the Major Medical Benefit

Unlimited and paid from the Major Medical Benefit, subject to preauthorisation.

LA Core

Unlimited and paid from MMB

Unlimited and paid from MMB, subject to preauthorisation.

LA Active

A co-payment will be applied to the hospital account paid from MSA. Remainder of hospital account paid from the Major Medical Benefit. Related accounts limited to funds in MSA/Extended Day-to-Day Benefit.

Please refer to your benefit brochure for the applicable co-payment

The scope account will be paid from the Major Medical Benefit. Related accounts will be paid from and limited to funds in MSA/Extended Day-to-Day Benefit, subject to preauthorisation.

LA Focus

A co-payment will be applied to the hospital account paid from MSA. Remainder of hospital account paid from the Major Medical Benefit. Related accounts limited to funds in MSA

Please refer to your benefit brochure for the applicable co-payment

The scope account will be paid from the Major Medical Benefit. Related accounts will be paid from and limited to funds in your MSA, subject to preauthorisation.

LA KeyPlus

Covered with no overall benefit limit in a KeyCare hospital, if referred by a specialist. Subject to preauthorisation.

Covered with no overall benefit limit in a KeyCare hospital, subject to preauthorisation.

Trauma Recovery Extender Benefit

This benefit is available to LA KeyPlus, LA Focus, LA Active, LA Core and LA Comprehensive members.

Certain claims linked to a traumatic event are paid from your Trauma Recovery Extender Benefit. We pay the claims from this benefit for the rest of the calendar year in which the trauma happened. Refer to your benefit brochure for the applicable limits

Overseas Claims

Prescribed Minimum Benefits will only be covered in full when these costs are incurred in South Africa.

In all other instances, when you travel outside of the borders of South Africa, you will have to pay for any healthcare and treatment and then claim from the Scheme when you are back in South Africa. The Scheme must receive with a detailed account, indicating the condition and all other details and costs.

LA Health will then convert the costs and pay you back in South African Rands at the exchange rates that applied when the costs were incurred.  Your actual available benefit will be as per the normal rules of the Scheme for your specific Benefit Option and all applicable limits will apply.

Specialised Medicine and Technology Benefit

LA Comprehensive members have cover for a defined list of the latest high technology treatments through the Specialised Medicine and Technology Benefit.  This benefit is limited for each person with a variable co-payment of up to 20% of the cost of the specialised medicine or technology, depending on the condition.

To have access to this benefit, please call us at 0860 103 933 to see whether we will cover your treatment

How to claim

When sending claims to the Scheme, please make sure you do the following:

  • Check your personal file with your doctor to ensure all your details are up-to-date
  • Check all your details against your membership card, especially your membership number
  • Ask if your doctor charges the Scheme Rate or a higher rate and negotiate with him or her to charge at the Scheme Rate
  • If your doctor sends the claim to the Scheme electronically, you do not need to send a copy to us
  • If you send your claim to the Scheme, please send the original copy with your correct membership number
  • Send us a detailed claim and not just a receipt. We need the details so we can process your claim
  • Make sure your membership number, doctor’s details and practice number are clearly visible on the claim.

By law, each claim must contain the following information:

  • The surname and initials of the member
  • The surname, first name and other initials, if any, of the patient
  • The name of the medical scheme concerned
  • The membership number of the member
  • The practice code, group practice and individual provider registration numbers issued by the registering authorities for providers, if applicable, of the supplier of service and, in the case of a group practice, the name of the practitioner who provided the service
  • The relevant diagnostic and such other item code numbers that relate to such relevant health service
  • The date on which each relevant health service was rendered
  • The nature and cost of each relevant health service rendered, including the supply of medicine to the member concerned or to a dependant of that member; and the name, quantity and dosage of and net amount payable by the member in respect of the medicine
Choose from several ways to send claims

There are various ways of sending claims to the Scheme for processing:

  • Send your claim electronically – by email to claims@discovery.co.za, or fax to 0860 329 252.
  • Drop off your claim at Discovery Health’s offices or at any other assigned Discovery Health claims box. You can find these boxes at Virgin Active or Planet Fitness gyms, Dis-Chem pharmacies or at most private hospitals.
  • Post your claim to the Scheme.

What happens after you send your claim

Once we receive your claim, we scan and capture it on our system. We will then assess the claim and make sure all the information on the claim matches the information we have on record for the patient.

It is then approved or declined for payment. Once we have made the payment, you will receive your claims statement detailing all the claims payments.

How to check on the status of your claim

To see the status of your claim, you can access the Claims Search tool or check your claim statement. Alternately you can contact the call centre on 0860 103 933.

If we have your email address, you can now receive a claims payment notification, that will provide you with all the information about the latest claims we have processed for you – how it was assessed against your available benefits, how it was paid and what the latest balances are – MSA or others.

Remember to log in and update your information on the website.

Claims Statement

In order to view your claims statement online, you will need to log in. Click here to log in now

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