The online portal enables healthcare providers to search for recent claims submitted, correspondence sent, calls made to Bestmed, as well as detailed member lookup.
Some of the CDL, PMB and non-CDL chronic conditions require additional clinical information in order to qualify for registration. Before Bestmed can process the application, it’s necessary for them to receive a report from the appropriate treating specialist together with specific clinical information. The conditions where additional information is needed, including the specific information required for each chronic condition, are listed in the table below.
A formulary is a list of medicines we will cover, according to Scheme Rules, for the treatment of the listed chronic conditions per option.
It’s a diagnosis code, indicating the health condition for which treatment is being received and is, therefore, compulsory on all medicine applications and prescriptions.
CDL and PMB are lists of chronic conditions for which a scheme must provide cover for the medicine and treatment of the condition. Note: Option specific inclusions/exclusions may apply.
These are additional chronic conditions which may be covered by the Scheme, depending on the member’s chosen benefit option. It’s not compulsory for the Scheme to fund treatment of these conditions. Refer to the comparative guide covered per option.
If a member has a general three- (3-) month waiting period, they are entitled to apply for CDL chronic and PMB benefits. If a member has a 12-month condition-specific exclusion, then the member cannot claim for any services related to that condition for a period of 12 months.
No. To access the chronic benefit, pre-authorisation is compulsory. Thus, it is the member’s responsibility to apply for chronic benefits.
The member and the treating doctor will be required to complete a chronic medicine application form. It is advisable that one presents the treating doctor with a copy of the medicine formulary as it applies to the specific Bestmed Scheme option and the specific chronic condition.
A generic reference price is a maximum set price a medical scheme is prepared to pay for a specific generic molecule for a specific dosage. Bestmed uses the Mediscor reference price (MRP) to set the generic reference price. A member can use the original medicine and pay the difference between the price of the chosen medicine and that of MRP (thus have a generic co-payment). Alternatively, the member can use a generic alternative within the reference price range and have no generic co-payment. Reference pricing is applicable to all medicines, including formulary and non-formulary chronic medicines, as well as acute and OTC medicines.
A co-payment is the portion of a claim payable by the member directly to the service provider.
A patient should only submit their prescription to Bestmed if their medicine has changed or if their authorisation is about to expire. However, the pharmacy will require a new repeat prescription every six (6) months in order to dispense their medicine.
Bestmed applies protocols and funding guidelines in their authorisation process. Should a member’s requested treatment fall outside of these funding guidelines, it will not be approved.
Chronic medicine claims can be submitted every 24 days.
The Medicine Supply advance application form should be completed and returned to Bestmed at least two weeks prior to the date of medicine collection:
A preferred provider is a pharmacy recommended for Bestmed members to obtain their medicine. Any pharmacy that charges a dispensing fee of no more than 33% (with a maximum of R33 excl. VAT) and charges no additional administration fees, can be regarded as a preferred provider.
Bestmed has negotiated with more than 1 300 pharmacies and has compiled a list of these preferred providers who will charge a dispensing fee the same as or lower than the Bestmed fee structure. Patients are advised to obtain their medicine from one of these preferred providers to avoid any dispensing fee co-payments. A complete list of these providers can be viewed under Pharmacies here .
If a member wants to apply for a specific service to be evaluated and approved from the PMB risk pool the following must be kept in mind:
The PMB application can be requested by contacting the Bestmed contact centre. This PMB application request form must be signed by both the member and provider and, if a dispute arises, further information may be requested by the Scheme. Bestmed’s decision-making is based on the relevant treatment algorithms of the PMB regulations, Scheme protocols, Scheme Rules, formularies and other managed care initiatives.
Once a decision is made by the PMB department, both the member and provider will be informed of the outcome of the PMB application request via email.
For any application received, an email will be sent to the practice, as well as the member, informing them of the decision that has been made by the PMB department.
If an application has been approved for retrospective services, Bestmed will arrange for the claim/s to be processed from the PMB benefit. Members will be able to view all corrections to claims on the emailed and/or posted claims statement.
A medical emergency is the sudden, unexpected onset of a health condition which needs immediate medical or surgical treatment. If the treatment is not provided, the person’s life would be at risk or result in serious impairment or dysfunction of a bodily organ or body part.
Bestmed covers patients for in-hospital emergencies. In the event of an emergency, the patient must immediately go to a hospital for medical care, but must remember to obtain an authorisation number within 48 hours of the consultation or on the first working day after the consultation.
Section 29 of the Medical Schemes Act requires medical schemes to stipulate the scope of minimum benefits in its Scheme Rules. Please refer to the registered Rules of Bestmed for further details.
The term specialised diagnostic imaging is used for scans and include all types of scans such as Computed Tomography (CT) scans, Magnetic Resonance Imaging (MRI) scans and Positron Emission Tomography (PET) scans. All of these services must be pre-authorised in order for the Scheme to cover the associated expenses.
The member, dependant, a family member with the necessary information, the radiologists’ rooms or referring provider can call in to obtain an authorisation number. Clinical information to support or motivate the application for funding will be required in order for authorisation to be granted (this information is usually supplied by the referring provider).
Because we are committed to client service excellence, Bestmed has introduced a variety of channels to access the Scheme and to make it more convenient for service providers to retrieve their information.
Your dedicated contact centre
The Bestmed contact centre is easily accessible:
Speak directly to a dedicated service providers consultant with regards to benefit options, claims, queries or even complaints.
For those who prefer to speak to a consultant face to face, we have a walk-in facility at our Head Office in Pretoria: Block A, Glenfield Office Park, 361 Oberon Avenue, Faerie Glen, Pretoria, 0081.
If a service provider is not satisfied with a response, then they may choose to escalate the process.
Should you be aware of any fraudulent, corrupt or unethical practices involving Bestmed, members, service providers or employees, please report this anonymously to KPMG.
Toll-Free from any Telkom line
Escalation of queries / appeals process
Any complaint must first be lodged with the scheme concerned. Written complaints would certainly be preferable but all schemes should also have dedicated telephone lines to handle everyday complaints and enquiries. All schemes are also required to have independent disputes committees where members’ disputes may be settled. Members and/or their legal representatives may be present at disputes committee meetings to present their arguments. Legal representation is not obligatory.
Bestmed continually strives to offer the best with value-for-money products supported by superior client service to make your dealings with Bestmed efficient and to your satisfaction.
1. Talk to us:
2. Dedicated provider assistance for complicated enquiries:
Disputes and complaints may also be posted to Complaints at Bestmed Medical Scheme, P.O. Box 2297, Pretoria 0001 or via email to firstname.lastname@example.org. It is important to follow the process depicted above as it will provide you with a response in the shortest possible time.
Who can complain to the Registrar’s Office?
Postal: Private Bag X34
Physical: Block A, Eco Glades 2 Office
420 Witch-Hazel Avenue