As an oncology patient, you have loads of questions, especially when dealing with your medical aid to ensure the best possible treatment is covered. Campaigning for Cancer helps navigate this tricky terrain by explaining terminology and the meaning behind it and offers services to help attain the best possible treatment.
What is the ICD 10?
The ICD-10 code (International Classification of Diseases, Tenth) is a classifying and codifying system used by physicians across the world to make diagnoses to make systems and procedures for claims processing simple and easy.
Our National Health Information System of South Africa (NHISSA) has adopted this standard, so it is used in both public and private healthcare.
ICD-10 coding translates diagnoses of diseases and other health-related problems from words to numbers and letters, codes which are consistent, predictable and reproducible, the meaning of which everyone in the system understands. ICD 10 coding is used to record, analyse, interpret and compare morbidity and mortality data collected in the country and across countries.
What are Prescribed Minimum Benefits (PMBs)?
A set of defined benefits that ensure that all medical scheme beneficiaries have access to certain acceptable basic health services for a number of common conditions or diseases, regardless of the benefit option they have selected; PMBs ensure continuous healthcare coverage for PMB conditions: even if a beneficiary’s benefits for a year have run out, the medical scheme has to pay for the treatment for PMB conditions without penalty to a beneficiary.
PMBs ensure that healthcare is paid for by the correct parties: medical scheme beneficiaries with PMB conditions are entitled to the specified treatments, the costs of which must be covered by their medical schemes, even if the beneficiaries receive care at a state hospital.
How do oncology benefits work in most medical schemes?
Once your oncologist has diagnosed you, your treatment must be pre-authorised (this is essential!); the medical scheme reviews the proposed treatment in line with registered scheme rules, protocols and formularies and provides a letter of authorisation. You’ll then go onto the scheme’s oncology programme and should familiarise yourself with the design of the oncology programme on your chosen plan.
Authorised cancer treatment is paid out of the oncology benefit, subject to scheme rules, normally over a 12-month cycle. Once the oncology benefit limit is reached, the medical scheme is obliged to cover the remainder of the treatment costs from the major risk pool, as long as the treatment in question is PMB level of care. Medical schemes are not allowed to cover PMBs from savings accounts.
How do I know my scheme is paying out of the oncology benefit?
Your letter of authorisation detailing whether or not treatment has been approved. should indicate that the treatment is approved for payment from an oncology benefit. If not, you must query this.
Campaigning for Cancer, through our Case Managers, aids patients and caregivers who have been denied or given limited access to treatment, benefits, medicine or healthcare. Patients have two options for lodging a case: via our online portal here:
https://campaign4cancer.co.za/wp/project-ask/
Or contact our Case Management team via:
e-mail address: casemanager@campaign4cancer.co.za; or
telephone: 082 2244 224.
NOTE: For more info about oncology benefits, scheme members are entitled to a copy of the most recently registered scheme rules, oncology benefits, protocols and formularies in terms of regulations 15H(b) and 15I(b), of the General Regulations to the Medical Schemes Act, 1998, as amended.
