Pre-authorization is a process where a member applies to the Fund before being admitted to hospital for approval of a procedure or treatment that requires hospitalization. The pre-authorization process determines the clinical necessity and appropriateness of the procedure according to the Fund’s clinical protocols and guidelines prior to hospital admission. It also serves as confirmation of the available benefits as per chosen option. Pre-authorization for Planned Procedures:
All admissions that are planned ahead of time are referred to as elective procedures. These must be authorised at least 14 days before your admission date. For any treatment that’s not an emergency (i.e that’s planned ahead of time), contact us as soon as you have finalised a date with your healthcare provider. We need at least 48 hours to process your request and may require additional information from your healthcare provider to process your request, which may cause a delay. Authorization for Emergency Cases:
In an emergency, authorization must be obtained as soon as you are admitted to the hospital. If you are admitted after hours, on the weekend or on a public holiday, authorization must be obtained on the first business day after the admission date.
If you require a pre-authorization number in less than 48 hours, please contact our Managed Health Care Department. We will give you a hospital authorization number, which you should write down and take with you to hospital.How to obtain Hospitalisation Pre-authorization:
The Pre-authorization Form for Hospitalisation is available on www.nmcfund.com (NMC)
Please complete the form and e-mail to firstname.lastname@example.org
or fax to 061-287 6176.
Our office hours are from Monday to Friday from 08h00 – 17h00.
If you require a pre-authorization number in less than 48 hours, please contact our Managed Health Care Department. We will give you a hospital authorization number, which you should write down and take with you to hospital.
When you contact us, please have the following information ready:
1. Your NMC membership number.
2. Your date of birth.
3. Name, surname and Date of Birth of the person being admitted.
4. The date of admission and the proposed date of the operation or treatment.
5. The referring / treating doctor’s name, practice number and telephone.
6. The name of the hospital, practice number and telephone.
7. The relevant procedure or treatment required (include also the equivalent NAMAF tariff code of the procedure or treatment, if provided by the referring / treating doctor)
Hospital Pre-authorization Confirmation letter:
Once your treatment or procedure has been pre-authorised, you will receive a confirmation letter by email, post or fax. This letter has important information about your hospital stay. Please make sure you read and understand it as it explains how your treatment or procedure will be covered. It will also include the following:
• Your pre-authorization number
• The approved length of your hospital stay Hospital Pre-authorization requests may be declined if:
• The procedure or treatment is not covered by your option chosen or a Fund exclusion.
• The procedure or treatment is not in line with the clinical and medical treatment standards for your condition.
• The information required for pre-authorization is not included.
• Your and/or your dependants membership is inactive or suspended.SUPPORTING DOCUMENTS