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Prescribed Minimum Benefits

Prescribed Minimum Benefits (PMBs) are minimum benefits that, by law, must be provided to all medical scheme members. This includes the provision of diagnosis, treatment, and care costs for:

  • A limited set of 271 conditions as specified in Annexure A of the Regulations to the Medical Schemes Act
  • A list of 26 chronic conditions which are also referred to as the Chronic Disease List (CDL)
  • An emergency medical condition refers to any sudden and/or unexpected health condition that requires immediate medical treatment

How do I apply for PMB benefits?

You need to keep the following in mind when applying for a specific healthcare service to be evaluated and approved from the PMB risk pool:

  • Only qualifying PMB ICD-10 codes will be considered for PMB benefits
  • The Bestmed PMB application form has to be completed and signed by you and your healthcare provider
  • If all the PMB criteria have been met and approval has been granted, your PMB condition(s) will be paid first from the day-to-day risk benefits, and only thereafter the difference will be covered as a PMB

Where do I submit my PMB application?

PMB applications can be

Please note: Based on the stipulations in the Medical Schemes Act and the Regulations of the Act, PMBs are funded from the Scheme’s risk pool. Therefore, a structured PMB process, which meets legislative requirements and supports cost containment, has been implemented for Bestmed members.

Resources

Please download the form you need and either fill in the interactive PDF on your computer or print out the form and complete it by hand.

+27 (0)12 472 6760

Bestmed, PO Box 2297, Pretoria, 0001

Downloads

FAQs

How do I know that my application has been approved?

You and your healthcare provider will receive an email with all the information relevant to the PMB Department's decision.

What happens once an application is approved?

If an application has been approved for retrospective healthcare service(s) rendered, Bestmed will arrange for the claim(s) to be processed from the PMB benefit. You will be able to view all corrections to claim(s) on the reconciled emailed and/or posted claims statement.

What happens if an account was short paid and the account has now been approved as a PMB?

Bestmed will arrange for the short payment to be made to the provider, or we will make a payment into your account upon receiving proof of payment from you.

If I have GAP cover, will it cover the shortfall on all my in-hospital accounts?

GAP cover may provide cover for the shortfall of in-hospital accounts which are not listed PMB cases. If the hospitalisation was for a listed PMB, you or the relevant healthcare provider's practice needs to apply directly to Bestmed to possibly approve the shortfall as a PMB.

Why should I use a designated service provider (DSP)?

Making use of DSPs may ensure that claims are paid in full. Exceptions are made in case of emergencies, where no DSP is available or where you cannot be accommodated within a reasonable time. You have the choice to voluntarily use non-network providers. However, they may be charged with higher fees or co-payments for your own account.

I still have questions. What should I do?

Any PMB applications and/or related PMB enquiries can be submitted by contacting our contact centre at +27 (0)86 000 2378 or service@bestmed.co.za.