Welcome to your Health Newsletter of Heritage Health Medical Aid Fund

We would like to wish you and your family a Blessed 2016 and good health. Heritage Health Medical Aid Fund is committed to communicate to our members and to provide healthcare relating information which is appropriate for you and your family. Heritage Health continuously seeks opportunities to improve our communication to our members and to improve our services.

What is underwriting? Why is underwriting required?

Underwriting is a process that is followed in terms of the Rules of the Fund and the pertaining regulations, in order to assess the legibility of potential clients and to manage risk associated with taking on new clients that may be considered a high risk. This process is put in place in the interest of all the members. The benefit options are available to all persons irrespective of their age. To manage the risk and the relating costs and to maintain accessibility and affordability all new applications need to go through the process of underwriting. Some of the criteria to be considered when it comes to the underwriting are, pre-existing conditions and the relating costs, age and life expectancy, previous medical aid cover and history of claims, the option being considered and chronic medication. When taking new members it always is important to ensure that the interests of all the existing members are protected. It would be unfair to increase the total membership of the Fund but to increase the risk and which will result in high monthly contributions making accessibility to healthcare cover unaffordable for the majority. Underwriting concessions is considered for larger employer groups.

What is Pre-authorisations and relating Case Management Reports?

For all hospital admissions whether in Namibia or in South Africa a pre-authorisation is required prior to admission for non-emergency treatments For all non-emergency procedures at least 48 hours, prior to obtaining the treatment or procedure, is required, to process the pre-authorisation. For all emergencies or after office hour admissions the hospital will contact Heritage Health administrator to obtain the necessary pre-authorisation. Hospitals are required to obtain the pre-authorisation within 48 hours from the time of admission.

What is the definition of an emergency?

Any emergency medical condition is a medical condition which is of sudden and unexpected onset that requires immediate medical or surgical treatment where failure to provide this treatment would result in serious impairment of bodily functions, serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.

Why do I require pre-authorisation?

The pre-authorisation process alerts Heritage Health administrator that a member/dependant is scheduled for hospitalisation; The patient, attending physician and hospital can be informed beforehand to what extent the treatment will be covered; The process enables heritage Health to curb ever-increasing medical costs as the cover of the member can be managed in such a manner that the most appropriate and cost-effective treatment is used; By complying with the process of obtaining pre-authorisation, you are assisting Heritage Health administrator in managing these costs and ultimately containing increases in monthly contributions; Pre-authorisation is granted based on the validity of your membership, clinical appropriateness, waiting periods, exclusions, length of hospital stay, terms and conditions of Heritage health and evidence based on clinical guidelines.

How do I obtain pre-authorisation?

To obtain a pre-authorisation number prior to admission, you, your attending physician or the hospital must contact Heritage Health administrator and provide the necessary clinical details. The office can be contacted via telephone, email or fax. Alternatively there is a pre authorisation form to be completed which is available via the website or can be obtained from the Heritage Health administrator office.

The following information must be provided:

• Policy holder/Membership number
• Patient: name and date of birth
• Treating doctor: name, telephone number and practice number
• Hospital: name and practice number
• Reason for admission
• Codes: Tariff and/or ICD-10 code(s)
• Date of admission and proposed date of the procedure

WHEN YOUR REQUEST IS AUTHORISED, YOU WILL RECEIVE:

• An authorisation number
• The approved number of days in hospital (if a stay is required)
• The tariff and ICD-10 code(s)

If your hospital stay is extended, the hospital case manager will inform Heritage Health administrator. Funding for additional days will be approved if:

• The request meets clinically-appropriate criteria
• It is within the Rules
• Benefits are available

Please Note: While every effort is made to establish member eligibility and availability of funds, authorisation is not a guarantee of payment. Although benefits are not payable while a waiting period is still in force, a member needing emergency trauma treatment within the general waiting may be covered subject to the terms and conditions under the Rules of Heritage Health and the available cover.

Case Management

Case management is used to track the treatment and costs of certain high cost cases, and ensures that the member is receiving the correct treatment and level of care. In order to Heritage Health administrator case managers up to date with the specific case and to obtain pre-authorisation, case management requires detailed clinical information of the particular hospital admission by the hospital, or treating service provider daily.

What is Casualty Benefit?

A casualty incident is an emergency incident which occurs after hours and for which you need to go to the emergency or after-hours division of a hospital. It is not something which may be obtained during normal working hours and which service is available at a doctor’s practice during the course of a day. Certain hospitals’ emergency division require a cash deposit at the time that the casualty division is being visited and which is not refundable. It is important to note that you must always have your Heritage Health membership card with you to. We caution all the members not to abuse this benefit and that this benefit must be utilised for the specific need as prescribed. Strict measure is applied to prevent abuse.