Medical Scheme Matters

Understanding the Authorisation Process

The medical scheme authorisation process for PET-CT scans involves independent assessment by your medical aid using their clinical guidelines and consultant specialists. This process typically takes 5-10 working days and may be extended if additional documentation or motivation letters are required from your referring physician.

Please note: Whilst we follow up frequently on each authorisation request, this process is managed entirely by your medical scheme and is beyond our direct control as the service provider.

How You Can Help Speed Up the Process

Contact Your Medical Scheme Directly: Patients who engage proactively with their medical scheme often achieve faster authorisation outcomes. We encourage you to:

• Contact the case manager at your medical scheme directly
• Provide the reference number for you application when calling
• Request status updates on your application

If we believe direct patient contact with your medical scheme would benefit your PET-CT application, we’ll provide you with all necessary information and contact details.

*Important* – What “Authorisation” Actually Means

Authorisation is not a guarantee of payment!

When your scan is “authorised,” it means:

• Sufficient funds were available in your benefit at the time of application
• Your medical scheme has approved the clinical necessity for the scan

However, authorisation does NOT a guarantee:

• That funds will still be available when we submit the claim
• Other claims that you have made haven’t depleted your benefits in the interim
• Payment, if your savings account or relevant benefits have been exhausted

You remain financially responsible if benefits are insufficient at the time of claim submission.

If Your PET-CT Request is Declined

Speak to TheraMed Nuclear and Your Referring Physician

PET-CT studies are authorised according to scheme rules, your membership plan and benefits, and the published guidelines for PET-CT in South Africa (Vorster M, Doruyter A, Brink et al, 2015. S Afr Med J).

Our Appeal Process:

If your application is declined, TheraMed Nuclear will review the reason for the refusal. When we believe the medical scheme is in error, we will appeal the decision on your behalf. Please be aware that:

• Appeals may lengthen the authorisation process
• Additional letters of motivation or clinical information may be required
• You and your referring doctor will be kept fully informed throughout this process

If Appeals Are Unsuccessful:

• You can choose to pay directly for the scan
• Further appeals to the Council for Medical Schemes may be successful: https://www.medicalschemes.co.za/

Additional Patient Information

Before Your Scan

Understand your excess: Know your annual threshold and current usage
Keep records: Maintain copies of all authorisation correspondence
Confirm your benefits: Ask your medical scheme advisor about the PET-CT benefits included in your scheme’s coverage

Financial Considerations

Co-payments: Some schemes require patient contributions even with authorisation
Benefit limits: Annual limits may affect coverage for multiple scans
Network providers: TheraMed Nuclear is a member of most available Designated Provider Schemes

Contact Information

If you need assistance with the authorisation process or have questions about your coverage, please contact our office. We’re here to support you through this process and will provide guidance on engaging with your medical scheme when beneficial.

This information is provided to help you navigate the medical scheme authorisation process. Individual scheme rules may vary, and we recommend confirming specific details with your medical aid directly.