If your doctor has referred you for specialised medical imaging, there’s a good chance you’ve come across the term “pre-authorisation”. If you are a first-time patient, you may be wondering what it means, when it is necessary, and what it entails.

We answer some common patient questions about this tricky term in radiology.

What is pre-authorisation?

Essentially, it’s an agreement from your medical aid provider, indicating a willingness to pay for costs associated with a certain procedure. Medical schemes typically require this step for hospital stays.

In radiology, medical schemes also require it for advanced imaging such as MRI and CT scans, PET-CT, and certain interventional procedures.

Even when a provider charges medical aid rates (as SCP does), pre-authorisation does not necessarily mean your medical aid will cover 100% of the costs. They may indicate a co-payment (an amount payable by the patient as prescribed by the fund rules) or cap the amount according to the policy terms. In some cases, other procedures on the same policy will influence the claim. The patient will be responsible for the balance.

Together with the request to the medical aid for pre-authorisation, you may ask your radiology practice for a quote. This will itemise the costs and provide a total for the imaging you have been booked for.

How is pre-authorisation obtained?

At SCP Radiology, we assist patients by submitting pre-authorisation requests to their medical aid, on their behalf. A request usually includes details about the patient’s medical condition, the proposed imaging (including the procedures’ tariff and ICD10 codes), and supporting medical documentation. Sometimes, the doctor who referred you will need to write a letter of motivation.

The medical aid will send the outcome of pre-authorisation request to both the radiology practice and you, the patient.

A pre-authorisation can be marked as follows:
A – Approved: Granting authorisation for the treatment or procedure.
D – Declined: Denying the request if the treatment is not covered, or does not meet the criteria for approval.
P – Pending: Requesting additional information or documentation to make a more informed decision.

Why is it necessary?

This step is necessary for the medical aid to verify that the imaging is medically necessary and for you to confirm that your policy covers the procedure.

What to remember

• It is crucial to submit the pre-authorisation request well before the planned procedure.
• After pre-authorisation is obtained, it is important to check what your medical aid has agreed to pay. Pre-authorisation does not guarantee payment or that your medical aid will pay the entire cost of the procedure. There may be limits or a co-payment depending on a number of factors such as:
  • The benefits and options the member has available on their medical aid to pay for the specific procedure.
  • The medical aid’s network of preferred providers.
• All pre-authorisation requests are evaluated against the different schemes’ rules and clinical funding policies. Even if a practice charges medical aid rates, the patient, or their guardian in case of a minor, remains responsible for any shortfall, including any co-payments.

What to expect

• If the radiology practice assists with obtaining pre-authorisation, the process will start after you have made an appointment. You will be informed of the medical scheme’s decision before your scan.
• When you arrive at the radiology practice for the imaging, you will be asked to sign various forms related to pre-authorisation, co-payments, and settling of the account.

This article is part of a series aimed at decoding medical jargon. Visit our news section for more.