Gap Cover FAQ’s

Are my dependants covered?

If you opt for a family premium policy type, your spouse and children may be added as dependants onto your policy.

Can shortfalls occur in any other way?

Yes, they can also occur if your medical scheme imposes co-payments or deductibles on certain procedures, e.g. MRI/CT scans or diagnostic scopes while in hospital.

Do all specialists charge more than the medical aid tariff?

A lot of them do and the charges vary from 1.5 times above what the medical scheme covers up to as much as 5 times more than the medical aid tariff.

How do I claim from my Gap Cover?

You can visit the website and either download a claim form or complete the online claim form.

How do these shortfalls occur?

They occur when your surgeon or anaesthetist charges more than what your medical aid pays for a procedure or specific code. This is called a ‘tariff’ shortfall.

How much is a co-payment or a deductible?

It all depends on your medical plan and on the type of procedure, but they range from around R2,000 up to as much as R15 000 per case.

How much is a tariff shortfall?

Tariff shortfalls vary according to the fees charged by your medical specialist and also the severity of the procedure. Typically, the shortfalls on minor procedures are several thousand rands and can be anywhere between twenty and forty thousand rands on large procedures.

How often does Gap Cover pay claims?

Gap Cover claims are processed daily and benefit payments payable to dependants are also made daily. Claims take 7 – 14 working days to finalise once all required documents are received.

If I would like to cancel, what is the notice period?

A minimum of 31 days’ notice is required in order to cancel your policy.

What is Gap Cover?

Gap Cover provides short-term insurance products that help you cover certain cost shortfalls between what your medical provider charges and what your medical aid pays.

What supporting documents are required in order to claim from my Gap Cover?

Fully completed claim form, copy of the Doctor’s (GP’s) invoice, copy of the hospital account and a copy of your medical scheme statement showing the shortfall.

Will all my shortfalls be covered by Gap Cover?

The policy does contain some exclusions, please refer to your policy document for the detailed list.

Will I have any waiting periods?

The waiting periods for Care are as follows :

3-month general waiting period;
10-month maternity specific waiting period; and
6-month procedure specific waiting period for:

• Joint surgery • Nasal and Sinus surgery •Tonsillectomy • Adenoidectomy • Grommets • Endoscopic and arthroscopic procedures • Hernia repairs • Hysterectomy • Cardiac surgery • Spinal surgery • Dentistry and cataract procedures.

Previously diagnosed cancer, within a period of 12 months preceding the date of inception, will be regarded as a pre-existing condition and Oncology Cover will be excluded for 12 months.  If proof of previous Gap Cover can be provided, the waiting periods will be reviewed and removed.

Medical Insurance Product FAQ’s

Dentistry

Can I go to any Dentist?

No, the Dentistry Benefit is only covered if you go to a contracted Network Provider. Pre-authorisation is required for procedures exceeding certain limits. Please view your policy document for a detailed breakdown of the dentistry Benefits and limits that apply to your chosen plan.

How do I access my dental benefits?

The Dental Benefit is only covered when making use of a contracted Network Dentist. The provider will be required to contact the call centre for confirmation of benefits or log in to the provider dashboard portal to validate Policyholder Benefits. A Dental Pre-Authorisation Request Form must be completed by the provider and submitted to dental.preauthorization@primecure.co.za. If the Benefit is approved, a letter of Authorisation will be emailed to the attending dental practitioner or therapist within three working days of receipt of the form. Please refer to your policy document for a detailed breakdown of dentistry Benefits and associated Authorisation requests.

What do I do if I require dental treatment over a weekend or after hours?

Weekend or after-hours dentistry is not covered on the Core plan. On the Plus plan, after hours Treatment is limited to one visit per Family per annum for pain and sepsis only. You may visit any Dentist, but you may be required to pay upfront and then claim back from the Network Provider. The Network Provider will refund the Policyholder at the Agreed Rate.

General

Can anyone join Kaelo Health?

For employer groups, an employee can join if they are permanently employed.

For individuals, you can join in your private capacity if you have a valid South African ID or passport and proof of banking details.

Do you issue Tax Certificates?

No, insurance products do not have any tax benefits to the individual taxpayer.

What are the call centre operating hours?

The call centre operates during the following hours: Monday to Friday: 08:00 to 17:00 and Saturday: 08:00 to 12:00. For after hour emergencies call NETCARE911 on 010 209 8364

What are the Tax Benefits to the Employer?

An employer can deduct their share of the Kaelo Health premium payment and receive corporate tax relief of 28% (or applicable corporate tax rate).

What is a waiting period and how does it work?

When you take out a Policy, there is a three-month waiting period before you can use the Doctor (GP), Dentist and Optometrist benefits, except for virtual consultations, where the three months waiting period does not apply and is subject to your available limits. If you have taken out Accident Cover, no waiting periods apply to treatments as a result of an accident. A newborn, Eligible Child or Spouse must be registered within 90 days by emailing applications@primecure.co.za and added to the Policy as a dependant, from the birth or marriage date. Premiums will be payable from the birth or marriage date. A three-month general waiting period may apply for a newborn, Eligible Child or Spouse not registered within 90 days of the birth or marriage date. The Insurer reserves the right to change the application of waiting periods by giving notice of 31 days before such a change.

Hospital Emergency & Accident Cover

Is the cost of the ambulance service covered?

Yes, in the event of a valid local emergency or serious accident, you or the hospital can contact Netcare 911 to request a Guarantee of Payment (GOP) once you have been transported to the closest appropriate facility.

Is there hospital cover for a medical condition?

We do not cover Hospital admissions unless the cause of the incident is related to trauma or an accident.

However, you can select the Medical Emergency Illness Cover Buy-Up Option as an add-on to the Accident cover. The Medical Emergency Illness Cover Buy-Up Option provides access to quality private health insurance should you or your Family have a Medical Emergency event due to an Illness as defined by the Policy.

What do I do in the event of a minor accident?

Call the call centre or visit the website or Mobile App to locate a Contracted Service Provider or the nearest out-patient facility that accepts a Guarantee of Payment, as some out-patient facilities only accept cash.
If after hours call Netcare 911 on 082 911 or 010 209 8364. Netcare 911 will arrange the Guarantee of Payment with the out-patient facility (casualty) and will send the Guarantee of Payment. We will create an Authorisation number within business working hours and then settle the account directly with the outpatient facility, subject to the benefit limitations of your specific plan. The patient must please ensure that they have their membership card and ID for verification purposes.

What do I do in the event of a serious accident?

Call the call centre or Netcare 911 on 082 911 or 010 209 8364 or hit the emergency button in the Mobile App. Netcare 911 will verify the membership of the person in need of help, whether it be the Policyholder or a Dependant. They will assist the patient with advice and emergency transportation to the nearest in-patient Hospital facility. They will issue the Hospital with a Guarantee of Payment and the Insured Party will be admitted for Treatment. We will create an Authorisation number within business working hours and then settle the account directly with the Hospital, subject to the Benefit limitations of your chosen plan.

What does emergency stabilisation mean?

It is the immediate Treatment administered to a person for a Medical Emergency condition to stabilise the patient before they are transferred to a facility for further management e.g. a heart attack at the scene of the accident by Netcare 911 before being transported to the appropriate Hospital. Subject to the benefit limitations of your chosen plan.

What is an emergency casualty department?

An emergency department, also known as an accident and emergency department, emergency room (ER) or casualty department, is a medical Treatment facility specialising in emergency Treatment of patients who arrive without a prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a Hospital or other primary care centres. Due to the unplanned nature of patient attendance, the department must provide initial Treatment for a wide range of Illnesses and injuries, some of which may be life-threatening and require immediate medical attention.
A designated section of a Hospital where people who are severely injured in accidents or suddenly become ill and need urgent Treatment are assessed and treated.

What is an emergency?

An emergency medical condition means the sudden, and at the time unexpected onset of a life-threatening health condition that requires immediate medical Treatment, where failure to provide medical Treatment will result in serious impairment to bodily functions, or serious dysfunction of a bodily organ or part, and would place the person’s life in serious jeopardy. Examples include heart attacks, strokes.

What is considered a trauma and accident event?

“Accident” or “Accidental Harm”: means bodily injury caused by violent, unintentional, external and physical means. Examples include motor vehicle accidents, severe burns, exposure to poison that is not self-inflicted.

Any injury or Treatment resulting from Accidental Harm. Treatment for an Accidental Event will be provided up to a maximum of 90 days calculated from the date of the Accidental Event, provided the Treatment and services have been authorised by calling the Prime Cure call centre and are directly related to the Accidental Event.

What is the casualty benefit if I have a trauma and accident event?

Emergency out-patient services will be provided in the case of Accidental Harm to an Insured when the Insured needs out-patient Treatment and is transported to the relevant Hospital by Netcare 911.
Please refer to your Policy Schedule for a detailed breakdown of the benefit and associated Authorisation requests. Netcare 911 will authorise the Benefit amounts to the relevant Hospital in the case of an accident (caused by an Accidental Event) services must be rendered at a Network Provider Hospital casualty. No Benefit is payable under this clause for services that are related to an Illness unless you’ve selected the Medical Emergency Illness Cover Buy-Up Option as an add-on.
Any Specialist or follow up visits for medical cases are not be covered under the Casualty Treatment Benefit.

What is the hospital benefit if I have a trauma and accident event?

Emergency in-patient services will be provided for in case of Accidental Harm to an Insured for in-patient Hospital Treatment. Please refer to your Policy Schedule for a detailed breakdown of the benefit and associated Authorisation requests. Authorisation must be obtained by contacting the call centre. The Benefit covers Treatment and services for a 90-day period calculated from the date of the Accidental Event. All Treatment during this period must be pre-authorised by contacting the call centre. Services must be rendered at a contracted Network Provider Hospital. No benefit is payable under this clause for services that are related to an Illness. Any Specialist or follow up visits will not be covered if not related to the Accidental Event.

What must I do if I require an ambulance?

In the event of an emergency or serious accident call NETCARE911 on 082 911 or 010 209 8364 and follow the voice prompts. Medical emergencies will be transported to a State Facility and Trauma and Accident emergencies will be transported to a Contracted Hospital Casualty.

Medical Insurance Claims

Do I need to claim for Medical Insurance?

You shouldn’t need to claim for Medical Insurance. Provided you are using Network Providers, claims are paid on your behalf to the provider through your Policy. In most cases, you will need to present your membership card and ID to the contracted Network Provider and they will submit the claim directly to us for processing and payment. To avoid claims not being paid, first check that you have gone to a Network Provider as well as make sure you haven’t already exceeded any limits on your Policy for the year. When claims aren’t automatically paid to the Network Providers, such as:

  • Specialist visits
  • When you visit a non-Network Provider
  • If your provider insists you pay in cash

You can fill out a reimbursement form within 6 months from the date of Treatment to claim for the service, subject to the available benefits and limits on your chosen plan.

How and when can I claim for Medical Insurance?

If you have paid for the services provided, you can submit the claim in any of the following ways:

IMPORTANT: The entire form must be completed for your refund to be processed. Your refund will be processed within 14 days of receipt of all the required information. Where no proof of banking details have been supplied, Prime Cure will not be held responsible for any payment made to the incorrect account.

If your provider sends you a paper claim, you can post the claim to:
Private Bag 2108
Houghton
2041

If the claim is sent to you electronically, you can email the claim to correspondence@primecure.co.za

Claims that are older than 120 days require proof that the claim was previously sent to Prime Cure. Failure to provide proof will result in the claim being rejected as stale.

How do I dispute a claim assessment?

A claim may be disputed by making representation to Kaelo or the Insurer indicated in the Disclosure Notice attached to the Policy wording within 90 days of receipt of the benefit/rejection letter. Kaelo or the Insurer is obligated to provide the Policyholder with feedback within 45 days.

The Policyholder should first aim to resolve their dispute with Kaelo before contacting the Insurer. Submit your concerns in writing to the Kaelo Risk Complaints Manager by emailing escalations@primecure.co.za where our Executive Office will assist you. Should you wish to speak to us, please contact us on 0861 665 665. Should you wish to submit your complaint to the Insurer, please submit this in writing to the Internal Complaints Department of Centriq, for attention of Centriq Complaints Department using complaints@centriq.co.za. If you are dissatisfied with the response from Kaelo Risk or Centriq Insurance Company Ltd, you are entitled to approach the Ombudsman for Short Term Insurance (OSTI) or the Ombudsman for Financial Service Providers (FAIS) external independent offices. This must be done within 180 days of being advised that your representations to the Internal Complaints Department of Centriq have been unsuccessful.

Finally, we remind you of the following policy condition: Our policy requires you to institute legal action within 180 (one hundred and eighty) days after the expiration of the 90 (ninety) day period referred to above, failing which you will forfeit your claim and no liability can arise in terms of such claim. To access our complaints process, visit our website at www.kaelo.co.za under the Contact menu item for more details.

How do I follow up on the status of a claim?

You can view claims received, processed, and paid on the Mobile App.

How do I request a refund for a claim I paid?

Send the following documentation to refunds@primecure.co.za  along with the refund request form which can be downloaded here:

  • A copy of your ID
  • The account for which the request is being made including:
    • The date of service
    • Practice number
    • Tariff/ICD-10 codes
    • Amount claimed.
  • Your receipt as proof of payment
  • Any requests over R3 000.00 must be accompanied by proof of banking details (stamped statement or confirmation letter).

Your refund will be processed within 14 days of receipt of all the information. Where no proof of bank details have been supplied, we will not be held responsible for any payment made into an incorrect account.

Mobile App

How do I access my Membership Card?

In the App on the menu tab select “Digital Card”. You can save your digital card on your phone as well as share it via WhatsApp, email or MMS.

How do I access the Mobile App?

You can download the Kaelo MyHealth App from the Google Play, Apple or Huawei App Store or by visiting https://www.kaelo.co.za/apps/.

How do I allocate Prime Cure Network doctors?

In the App on the menu tab select “Find Doctor”. The Mobile App will take you to the Prime Cure website where you can choose the type of Doctor you need and the area.

How do I check my benefits?

In the App on the menu tab select “Benefits”. There you will be able to view your: Brochure, Policy, Disclosure and Renewal Notice.

How do I reset my password?

To reset your password in the Mobile App, select the “Forgotten Password” button. A temporary password will be sent to you via the preferred communication you selected during app registration (SMS or email). Log in to the App using the temporary password to create a new password. If any of your details have changed, contact the call centre to update your profile. Please have your registration details with you.

What features are available on the App?

The Mobile App allows you to easily access important policy documents and has many other useful features such as:

  • An emergency button for easy emergency assistance
  • Access to your membership details, digital membership card and membership certificate
  • A useful summary of your plan details and limits
  • A benefit dashboard
  • Tracking of your Doctor (GP) visits and medication
  • Tracking claims received, processed and paid
  • Finding your closest Doctor (GP), Dentist, or Optometrist
  • Authorisation requests
  • Communication, policy document and brochures
  • Logging queries for assistance
  • Book a Virtual Consultation
  • Contact details for any enquiries
  • Answers to frequently asked questions

Nurse and Wellness Clinic Based Care

How do nurse consultations work?

You can consult with a nurse at a Network Wellness Clinic at a contracted pharmacy. In many practices, nurses can provide scripts for minor ailments for up to schedule 2 medications. Please refer to your policy document for the wellness clinic limits that apply to your specific plan.

Is there a limit to nurse consultations?

Yes, visits per Insured Party are limited in respect of the following:

  • General colds and flu
  • Bronchitis or asthma
  • Diabetes
  • Screening and wellness
  • Testing for HIV

Please refer to your Policy Schedule for the detailed Benefits and limits that are applicable to your specific plan. You can use your Over the Counter (OTC) Benefit if the nurse suggests OTC Medication.

What is the Nurse Benefit?

The Nurse and Wellness Clinic Benefit is for the Treatment of minor Illnesses such as coughs and colds at a Network Wellness Clinic at a contracted pharmacy. Visits per Insured Party are limited as follows:

  • General colds and flu are limited to four events
  • Bronchitis or asthma is limited to two events
  • Diabetes is limited to two events
  • Screening and wellness is limited to two events
  • Testing for HIV is limited to two events

You can use your Over the Counter (OTC) Benefit if the nurse suggests OTC Medication. You may only visit a contracted pharmacy that has a Wellness Clinic. The claim will be submitted by the pharmacy clinic directly to Prime Cure for payment.

What is the Screening Benefit?

You may visit any Network Wellness Clinic at a contracted pharmacy twice a year for a health screening.

The health screening consists of the following tests:

  • Blood pressure
  • BMI (Basal Metabolic Index)
  • Finger prick cholesterol test
  • Finger prick glucose (blood sugar) test
  • HIV/Aids test including pre- and post-test counselling.

The claim will be submitted by the contracted Wellness Clinic directly to Prime Cure for payment.
You must contact the nearest contracted Wellness Clinic for an appointment, at least 72 hours’ notice is required.

Optometry

What is my Optometry benefit?

There is no Optometry Benefit on the Vital Option. On the Core and Plus plans, you can visit a contracted Optometrist once every 24 months. Failure to visit a contracted Optometrist will result in the account being your responsibility. You are entitled to one set of clear CR39 single vison or clear CR39 bi-focal glasses every 24 months. In order to qualify for glasses, your eye examination results must meet the qualifying norms.
You will need to choose frames from the Prime Cure selection of frames. If you choose frames that are not in the Prime Cure range, you will need to pay the difference. We do not cover tinting or contact lenses.

Pharmacy and Medicine

Can I get medication without a script from a Doctor (GP)?

Yes, you can consult with a pharmacist or nurse at an approved pharmacy, and they can suggest Over-the-Counter (OTC) Medication (medicine which does not require a script) for minor ailments. OTC Medication must be on the OTC Formulary and is limited to schedule 0-2 medicines, subject to your available limits on your chosen plan.

Can I go to any pharmacy?

You must go to a Contracted Network pharmacy to get your medicine. If you use a non-contracted pharmacy, your medicine will not be covered. All Dis-Chem, Pick n Pay and Clicks pharmacies are approved on the Prime Cure Network. To find a pharmacy in the Prime Cure Network, you can visit the Prime Cure website or log in to the Mobile App.

Can the pharmacy deliver my medications?

Yes, some pharmacies do offer delivery services. You can arrange with your selected pharmacy.

How do I find an approved pharmacy clinic?

All Dis-Chem, Pick n Pay and Clicks pharmacies are approved on the Prime Cure Network. To find a network pharmacy near you, visit the Prime Cure website or the Mobile App.

My dispensing provider did not provide me with enough medication?

As per legislation, a consultation is confidential and between a Doctor (GP) and patient. The Doctor (GP) will use their discretion to determine the correct dosage (how much medicine) to prescribe or provide to the patient. It is best to consult with your Doctor (GP) if you need more medication.

What is a formulary?

A formulary is an approved list of medication covered by our policies. The Policyholder can normally find both generic and brand name medication on the formulary. Visit this link to view the Medicine, Dental and Highly Active Antiretroviral Therapy (HAART) Formularies. Formulary prescription medication is chosen for its cost, effectiveness, and safety. Medication that is not on the formulary will not be covered, and will be paid for by the Policyholder.

What is acute medication?

Acute Medication is medicine that is used for diseases or conditions that have a rapid onset, severe symptoms and/or only need a short course of medicinal Treatment. Acute Medication must be prescribed by a Prime Cure contracted network Doctor (GP). Only medication on our Acute Formulary (medicine list) will be covered. Acute Medication must be provided by either a dispensing Doctor (GP), or a non-dispensing Doctor (GP) will give you a script to take to a Contracted Provider network pharmacy.

What is chronic medication?

A Chronic Condition is a disease that lasts three months or longer and generally cannot be prevented by vaccines or cured by medication. A Chronic Condition also doesn’t disappear after a short course of medication. A Chronic Condition can be treated by medication that will likely be taken for a lifetime to manage the condition. Chronic Medication is medicine prescribed by a medical practitioner for an uninterrupted period longer than three months. Please refer to your Policy Schedule and Brochure for detailed benefits on the Chronic Conditions covered under your specific plan.

What is Over the Counter (OTC) medication?

Over the Counter (OTC) Medication is medication received or advised by a pharmacist and is for the Treatment of minor Illnesses. OTC Medication is limited to the Prime Cure Medicine Formulary. Medication must be dispensed by a Prime Cure contracted network pharmacy. Please refer to your policy document for the Benefit limits that apply to your specific plan.

What is the chronic medication benefit?

Chronic Medication will be covered in full, at 100% of the Agreed Rate if:

  • The prescribed medication forms part of the approved Chronic Medication Formulary (medicine list).
  • You have registered for Chronic Medication with a Contracted Service Provider.

Chronic Medication is unlimited according to the Prime Cure Medication Formulary for an approved list of Chronic Conditions. To view the full list of qualifying conditions for your specific plan, please visit your policy document. You must ensure your Chronic Medication is registered on the Chronic Medication programme and compliance to Treatment guidelines will influence the Prime Cure protocol.

To register for this Benefit:

You must get your medication from a Prime Cure contracted pharmacy.

What is the process for applying for chronic medication?

All Chronic Medication is subject to a registration process by your allocated and contracted network Doctor (GP). After the Doctor (GP) has diagnosed you with a Chronic Illness, they will register your Chronic Medication by emailing a completed CDL Chronic Application Form, copy of the prescription and if necessary, supporting documents to preauth@mediscor.co.za for Chronic Medication or HIVDMP@primecure.co.za for HIV registration.

All Chronic Medication needs to be registered from the first script. Some medication may require additional information, like laboratory test results for the medication to be approved. Prime Cure contracted Doctors (GPs) are aware of the requirements.

Chronic Medication that does not require additional information can be obtained as Acute Medication for the first script while the Chronic Medication registration process is completed. After completion of the application process, you may obtain your Chronic Medication at a Network Provider contracted pharmacy.

Where can I get my chronic medication?

Once your Chronic Medication has been approved, you may collect it from any contracted pharmacy.

Policy Holder

Am I covered for overseas travel?

No, international cover is not provided.

Do I need authorisation for maternity benefits?

Yes, you do need pre-authorisation to access the Maternity Benefit, which is subject to the Benefit limits on your chosen plan. Once you have selected your Network GP or Gynaecologist you or the provider should contact the call centre and request to speak to a Case Manager for pre-authorisation.

How is cover cancelled?

You may cancel your cover at any time, by giving 31 days prior written notice via email to applications@primecure.co.za. The Insurer may cancel the Policy by giving 31 days’ notice for any reason. The Insurer may alter the Benefits or the basis upon which Benefits are calculated under this Policy by giving 31 days written notice thereof. Cover or services provided will only be valid if the Treatment or service was provided prior to the Termination Date. In the event that any fraudulent act is committed by any Insured Party, the Insurer reserves the right to immediately cancel this cover and/or to institute legal proceedings against the relevant party to recover any losses. Premiums are payable up to and including the Termination Date.

My debit order didn’t go through, what should I do?

Please contact your broker or contact the call centre on 0861 665 665 or email billing@kaelo.co.za.

What do I do if a benefit requires pre-authorisation?

To access the Benefit, you will require a pre-authorisation number. Log in to the Mobile App and navigate to the My Benefits section. Alternatively, you can contact the call centre and select the option for pre-authorisations.

What happens if my employer does not pay my premium on time?

Benefit coverage will be suspended, and any claims submitted during the time of suspension will only be paid once Premium payments are up to date. If Premiums are not paid for two consecutive months, and there are no attempts to pay Premiums that are in arrears, the Policy will be cancelled. Please note that the Policyholder is liable to settle any provider claims that have been rejected due to membership status being suspended or terminated.

What is an exclusion?

An exclusion refers to the list of services and conditions which are always excluded from cover. Please refer to your Policy Schedule for more information about the exclusions on your chosen plan.

What is pre-authorisation and when do I need it?

There are times when you are required to get pre-authorisation before using a Benefit, to avoid a claim not being paid. Please check your Policy Schedule to understand which benefits require pre-authorisation for your chosen plan.

What should I do if my contact details have changed?

Please inform your broker of any contact or address changes. You can also update your information in the Kaelo MyHealth App, contact the call centre on 0861 665 665 or email applications@primecure.co.za. It is very important to keep your details up to date so we can effectively communicate with you and to ensure that we can assist you as fast as possible in the case of an emergency.

Where can I get my membership card?

Your card will be printed and dispatched after your first Premium has been paid. If you have not received your card within 30 days after the first Premium is paid, you should contact our call centre or email MyHealthlettersandcards@kaelo.co.za. Your Policy Schedule will be emailed to you. You can use your Policy Schedule to access benefits before receiving your membership card. An electronic version of your membership card is also available on the Mobile App.

Will my policy premium be adjusted and if so, how frequently?

Our products are rated annually with adjustments taking effect on 1 January of every year, however, we do reserve the right to adjust the Premium with 31 days written notice. Adjustments are based on various factors including, but not limited to, loss ratio experience, medical tariff increases and inflation, changes in the group demographic profile and benefit changes.

Prime Cure Network

How do I find a Prime Cure Network Provider – Doctor/Dentist /Optometrist etc?

To find a Prime Cure Network Provider:

What is the Prime Cure Network?

Prime Cure is an accredited managed healthcare organisation providing health care via a network of more than 10 000 healthcare service providers including Doctors (GPs), Dentists, Pharmacists, Optometrists, Specialists and Private Hospitals.

What should I do if there is no network provider close to where I live or work?

Contact the call centre and we will try and find providers in the area. If we cannot reach one, we will make an arrangement to pay your Doctor up to a cost limit, subject to the available limits of your chosen plan. Alternatively, you can substitute your Doctor (GP) visits with a Virtual Consultation. You can book a Virtual Consultation through the Mobile App or our website.

Private Doctors (GPs)

Can a dispensing provider issue a script?

A dispensing provider may issue a script if they recommend a medicine that is not kept in their rooms. These medicines are usually a higher schedule medicine and will not be covered. Please note that if your provider is a dispensing Doctor (GP), they are paid for services that include the consultation and prescribed medicine on the approved Prime Cure Formulary (medicine list).

Can I go to any Doctor (GP), Dentist or Optometrist?

You need to go to a Prime Cure Network Provider (GP, Dentist etc) to avoid any unnecessary out-of-pocket payments. However if you are on the Plus plan, you have one visit to a non-contracted Doctor (GP) per Insured Party per annum, with a limit of two non-contracted visits per Family per annum. You are required to get Authorisation before you visit a non-contracted Doctor, and there is a cost limit per visit.

Can I use a non-network Doctor (GP)?

You may only visit a non-contracted Doctor (GP) if you are on a Plus plan. When visiting a non-contracted Doctor (GP), emergency medical facility or Contracted Doctor (GP) after hours, Insured Parties are limited to one visit per Insured Party per annum, up to a maximum of two visits per Family per annum, and paid up to a limit of R 1100.

As the Doctor (GP) is not contracted, you may need to pay upfront and claim back from Prime Cure. Following the consultation, please contact Prime Cure within 72 hours to obtain an Authorisation Number and submit your claim and proof of payment. Failure to obtain an Authorisation within 72 hours will result in the claim not being refunded by Prime Cure.

Do I need to get authorisation every time I consult with the Doctor (GP)?

You will need to obtain pre-authorisation for Doctor (GP) visits, depending on your chosen plan. On the Core and Vital plans, you do not need to pre-authorise your visits to a Contracted Service Provider – Doctor (GP).

On the Plus plan, you will need to pre-authorise visits from the fifth consultation to a Contracted Doctor (GP), per Insured Party.

Please refer to your policy document for the detailed Benefits and limits that are applicable to your plan.

How do I access Virtual Consultations for Family, Legal and Financial Counselling?

With Kaelo Virtual Consultations, you will be able to see a Lifestyle Professional  via video conferencing technology. In order to book a Virtual Consultation, you will need a Computer or Smart Phone with video functionality as well as a working internet connection.

You can book your consultation by selecting the relevant product and completing a short form. Once we have your details, you will receive an invitation via SMS or email.

How do Virtual Consultations work?

In addition to Doctor (GP) visits, you have access to Virtual Consultations via the My Telehealth Platform on the Mobile App or website. This Benefit provides access to Virtual Consultations with a Contracted Network Doctor (GP). Your available Virtual Consultations are subject to your chosen plan.

On the Plus plan, you have unlimited Virtual Consultations per Insured Party, per annum.

On the Core plan, you have four Virtual Consultations per Insured Party, per annum. You can also substitute your available Contracted Network Doctor (GP) visits for Virtual Consultations.

On the Vital plan, you have two Virtual Consultations per Insured Party, per annum. You can substitute your available Contracted Network Doctor (GP) visits for Virtual Consultations.

To book a Virtual Consultation online, log in to the Mobile App and under “My Benefits” select “Book a Virtual Consultation”, or book a consultation on the website by selecting “Self-Service” and then “Virtual Consults”.

You can also contact the call centre on 0861 665 665 and request a virtual consultation.

What if my existing Doctor (GP) is not a Prime Cure Network provider?

You can submit a request to have your Doctor (GP) loaded onto the network. Call the call centre and ask for a provider request form. Fill out the form with your Doctor (GP) details and email the form to provider.loading@primecure.co.za. The network team will contact the Doctor (GP) and advise you whether the Doctor (GP) decided to join. Should they decline, then you will be referred to a nearby Prime Cure Network Provider.

What is my Doctor (GP) Benefit?

On the Plus Option, the Doctor (GP) Benefit is unlimited. You are required to pre-authorise your Doctor visits from the fifth consultation. On the Core and Vital Options, you are limited to four visits per Insured Party per annum.

What is required when visiting a Doctor (GP)?

Ensure your Doctor (GP) is a Prime Cure Network Doctor (GP) and that you have available Doctor (GP) visits and pre-authorisation, depending on your chosen plan. When you visit a GP:

  • Take your membership card or use your digital membership card in the Mobile App, and your ID, passport or drivers licence with you. This will allow your Doctor (GP) to check that your membership is active and that you do have Benefits available.
  • Check with your Doctor (GP) that your Treatment or prescribed medicine is on our list of covered services.
  • Ensure your Premium payments are up to date.

What is the difference between a dispensing and non-dispensing provider?

A dispensing provider is a Doctor (GP) that can prescribe medicine from a list of approved medicines on our formulary (medicine list) and dispenses the medicine to you after your consultation. If the dispensing Doctor (GP) does not have the specific medicine that you require, they might give you a prescription to take to a pharmacy. The pharmacy will ask you to pay cash for the medicine, as dispensing Doctor (GP’s) are paid an additional fee to provide medicine directly to our Policyholders.

A non-dispensing provider will give you a prescription that you can take to a pharmacy to get your medicine. If the non-dispensing Doctor (GP) prescribes medicine that is not covered on our list of approved medicines on our formulary (medicine list), you will need to pay cash for the medicine at the pharmacy.

What should I do once I have reached my Doctor (GP) visit limit?

This depends on your scheme plan and option. Please refer to your policy document for the detailed Benefits and limits that are applicable to your chosen plan. Contact the call centre during office hours to request Authorisation for your GP visit before the consultation.

Specialists

How do I access the Specialist benefit?

The Specialist Benefit is only available on the Plus Option. You must be referred by a Contracted Service Provider and have pre-authorisation before the visit. Contact the call centre or email auth@primecure.co.za to obtain an Authorisation. We cover Specialist claims at the Agreed Rate. The Specialist consult is paid at an Agreed Rate, should a specialist charge above the Agreed Rate, you will be liable for the balance. The majority of Specialists are not contracted and will require you to pay upfront and claim back. The pre-authorisation number should be recorded on the account for payment to avoid any claims being rejected.

How do I claim/request a refund for a specialist consultation?

You can submit the claim via the Prime Cure website or email the claim to refunds@primecure.co.za. You will need to submit:

  • A completed refund form.
  • A copy of your ID.
  • The Specialist account for which the request is being made.
  • Receipt to show proof of payment.
  • Proof of your banking details (Either a bank stamped statement or confirmation letter).
  • Include the word refunds in the subject line of your email.

The refund will be processed within 14 days of receipt of all the required information and supporting documents. We will not be held responsible for any payments made to the incorrect account if no proof of banking details is supplied.

What is required to request Specialist authorisation?

Contact the call centre or email casemanager@primecure.co.za and supply the following information:

  • Name and surname of the Insured Party requiring the Authorisation.
  • Your Policy number.
  • The name and Practice number of the referring Doctor (GP) if applicable.
  • Name and practice number of the Specialist.
  • Banking details of the Specialist.
  • ICD 10 code or diagnosis from the Specialist if not supplied by a referring Doctor.

The Authorisation is valid for one month. Most Specialists are not contracted and you will be required to pay upfront and then claim back from the Network Provider. Any account in excess of the Agreed Rate will be the responsibility of the Policyholder.

What is the Specialist benefit?

This Benefit is only available on the Plus Option. You can visit a Specialist which includes all additional services related to the consultation, such as radiology, pathology, scans, medication etc. The Specialist Benefit will only apply if you are referred by a Contracted Service Provider, and you have obtained Authorisation before the visit. For Authorisations, contact the call centre on 0861 493 587. Please refer to your policy document for a detailed breakdown of the Benefit limits and associated Authorisation needed.

X-rays and Blood Tests

Do I need a specific form for pathology/radiology test referrals?

Yes, please make sure that only the Prime Cure pathology/radiology form for tests/referrals are completed and given to you before going for these tests. All tests not listed on these forms are not covered and will be for the patient’s account. The applicable form must be completed by the referring Network Provider:

For radiology – https://www.primecure.co.za/radiology-request-form/
For pathology – https://www.primecure.co.za/pathology-request-form/

What if I require blood tests or x-rays?

The pathology and radiology Benefits are subject to the Doctor (GP) limits. If your Doctor (GP) needs to send you for basic blood tests, black and white x-rays and soft tissue ultrasounds, we will pay the account if the Doctor (GP) is a Prime Cure Network Provider and the blood tests and or X-rays and or soft tissue ultrasounds, are on the approved cover list.

You must take the pathology request to a contracted pathologist. The following pathologists are contracted by Prime Cure:

  • Ampath Laboratories
  • Pathcare Laboratories
  • Lancet Laboratories
  • Lab 24

There is no cover for specialised radiology – MRI, PET Scans and CT Scans. You can take the black and white X-rays and/or soft tissue ultrasound request form to any radiologist.

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