Our website is best
viewed in portrait

Please rotate your display

Scroll to top

24h Emergency: 084 124

Register

The online portal enables healthcare providers to search for recent claims submitted, correspondence sent, calls made to Bestmed, as well as detailed member lookup.

FAQs

Chronic Benefit Programme

Are there specific requirements when registering for CDL, PMB or non–CDL chronic conditions?

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.

What is a formulary?

A formulary is a list of medicines we will cover, according to Scheme Rules, for the treatment of the listed chronic conditions per option.

What is an ICD-10 code?

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.

What are the Chronic Disease List (CDL) and Prescribed Minimum Benefit (PMB) conditions?

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.

What is a non-CDL chronic condition

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.

What is a treatment plan?

For every CDL and PMB condition where medicine is approved, a basic treatment plan is provided. The treatment plan differs from condition to condition and can include consultations, pathology, diagnostic imaging, etc. For each approved service, there is a maximum allowed per year at specified interval periods over a 12-month period. These services are paid from the day-to-day limit first, where applicable. Once the limit is depleted, claims will continue to be paid from Scheme risk up to the maximum quantity specified in the treatment plan. The treatment plan allocations are reset in January every year.

General waiting periods and exclusions

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.

Is the chronic medicine benefit applied automatically?

No. To access the chronic benefit, pre-authorisation is compulsory. Thus, it is the member’s responsibility to apply for chronic benefits.

How does one apply for chronic medicine 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.

Call +27 (0)86 000 2378 or click here to obtain an application form. Completed application forms can be sent by fax to +27 (0)12 472 6760 or emailed to medicine@bestmed.co.za.

 

What is generic reference pricing?

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.

What is a co-payment?

A co-payment is the portion of a claim payable by the member directly to the service provider.

When do co-payments apply?

  • When the medicine being used is not on the medicine formulary
  • If the medicine being used is more expensive than the reference price
  • When the provider charges a higher dispensing fee than that which the Scheme reimburses
  • Approved non-CDL formulary medicine has a standard co-payment for specific options as defined in the Scheme rules

What should I do if a member’s chronic prescription changes?

You need to submit a copy of the member’s prescription and membership details by email to medicine@bestmed.co.za or fax to +27 (0)12 472 6760.

How often should a member submit a chronic prescription to Bestmed?

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.

Why is a member’s medicine rejected even though the condition is covered on their benefit option?

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.

How often can a member claim for approved chronic medicine?

Chronic medicine claims can be submitted every 24 days.

What happens if the member needs an advance supply of their medicine if they are travelling?

The Medicine Supply advance application form should be completed and returned to Bestmed at least two weeks prior to the date of medicine collection:

  • The information can be emailed to medicine@bestmed.co.za or faxed to +27 (0)12 472 6760
  • Please attach a copy of the flight ticket or travel document to the application
  • Please attach a copy of the prescription for the medicine required for collection
  • Once the information is received, the member will be contacted within 48 hours via email

Who are the preferred providers for medicine?

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 .

What are the contact details for chronic medicine enquiries or information?

Prescribed Minimum Benefits (PMBs)

How does one apply for PMB benefits?

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:

  • Only qualifying PMB ICD-10 codes will be considered for PMB benefits
  • The Bestmed PMB application form has to be completed by the treating provider, as well as the member for this request to be considered for PMB benefits and the necessary clinical supporting documents need to be submitted
  • If all the PMB criteria have been met, funding for PMBs firstly come from the available day-to-day benefits and only thereafter the difference will be covered as a PMB

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.

 

 

How do I know that my patient’s application has been approved?

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.

What are the contact details for information and enquiries about PMBs (in and out of hospital)?

What happens once an application is approved?

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.

Where can the PMB application form be obtained?

The form is available from Bestmed’s contact centre at +27 (0)86 000 2378, by emailing a request to pmb@bestmed.co.za or sending a request by fax to +27 (0)12 472 6760.

What is an emergency?

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.

Diagnostic Imaging

What is specialised diagnostic imaging?

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.

Who can obtain pre-authorisation?

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).

What information will be required in requesting authorisation for a scan?

  • The patient’s member number
  • Name of member or beneficiary and date of birth
  • Date of CT/MRI/PET scan
  • Name of the treating specialist/referring specialist and the practice number
  • Name of the radiologist and practice number
  • The reason for the CT/MRI/PET scan
  • The ICD-10 code/s
  • Tariff codes to be used for the CT/MRI/PET scan

Contacts

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.

Report fraud

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

+27 (0)80 111 0210

+27 (0)80 020 0796

Postal: KPMG Hotpost BNT 371
P.O. Box 14671
Sinoville
0129
South Africa

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:

3. Need further assistance?

Disputes and complaints may also be posted to Complaints at Bestmed Medical Scheme, P.O. Box 2297, Pretoria 0001 or via email to service@bestmed.co.za. It is important to follow the process depicted above as it will provide you with a response in the shortest possible time.

You may also contact Bestmed Contact Centre on +27 (0) 86 000 2378 or the Service Providers Department on +27 (0)12 472 6434

Who can complain to the Registrar’s Office?

  • Any beneficiary or any person who is aggrieved with the conduct of a medical scheme can submit a complaint
  • It is, however, very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the Council for assistance
  • Complaints can be submitted by any reasonable means such as a letter, fax, email or in person at the CMS offices from Mondays to Fridays from 08:00 to 16:30

+27 (0)86 673 2466

Postal: Private Bag X34
Hatfield
0028

Physical: Block A, Eco Glades 2 Office
420 Witch-Hazel Avenue
Eco Park
Centurion
0157