Member Information

Frequently asked questions

Who is MSO?

Medical Services Organisation (MSO) is a leading provider of health risk management services to over a million beneficiaries of medical schemes and other forms of medical insurance throughout Africa.
MSO is part of EOH Health, a division of EOH Abantu (Pty) Ltd. EOH Abantu is wholly owned by EOH Holdings Ltd, which is a JSE listed company and was ranked fourth amongst 400 listed companies in Financial Mail’s Top Companies Survey. As a contributor to South Africa’s drive for transformation, EOH are proud to have achieved the BBBEE status of a Large Enterprise Level 2 contributor, with 156% BEE procurement recognition.
As an EOH company, MSO provides clients with the security and stability of doing business with a listed entity, while continuing to provide its clients with independent and expert hospital benefit, disease management, medical assistance, cost containment, direct billing and provider network management on the continent.

What does the Hospital Benefit Management entail?

The program consists of three interrelated services, namely pre-authorisation, case management and clinical audit. It begins with the pre-authorisation of all hospital admissions. The call centre is manned by qualified nurses and supported by experienced medical practitioners that follow specifically designed medial protocols and guidelines to apportion the appropriate level of hospital resources in relation to the clinical needs of the patient and considering the benefit entitlements a beneficiary has available from his selected medical scheme or insurance product, and monitor the quality and cost of care provided for all hospital admissions.

Case management commences on admission to hospital for all major surgery and serious illness, or when a meaningful complication took place. All case managers are registered nurses with many years of practical experience. To ensure optimal recovery, the appointed case manager will liaise with the doctor or specialist to ensure that all patients receive the best possible and most appropriate care. Another function of the case management process is assisting members with discharge planning, post-hospital care, as well as the possible transfer to more appropriate facilities such as for example rehabilitation and convalescent facilities.

All hospital claims are assessed retrospectively against the pre-authorisation budget. Qualified clinical auditors identify variances, and negotiate discounts or reductions with the hospital.

How does hospital benefit management benefit the member?

The purpose is to ensure that members and their beneficiaries receive quality care, delivered in the most appropriate setting through a process that encourages effective, efficient and consistent utilisation of healthcare services with the resulting appropriate allocation of resources. The appropriate utilization protects schemes and beneficiaries against the impact of unmanaged medical inflation.

Why is pre-authorisation necessary?

Pre-authorisation ensures that the proposed treatment or procedure in hospital is the most appropriate and cost-effective. Clinically based evidence (medical protocols), will be a critical factor in the scheme’s decision in consultation with the scheme's Clinical Advisors, to either limit or deny funding or propose alternative appropriate treatment for a proposed procedure. This provides you with the peace of mind that all expenses incurred during your hospital stay are approved and covered, whilst at the same time receiving optimal care.

What benefits require pre-authorisation?

  • Any procedure or treatment that requires admission to hospital, E.g. Tonsillectomy, back surgery, gynaecological procedures, etc.
  • Specialised radiology in and out of hospital, e.g. MRI and CT Scans;
  • Specialised conditions such as oncology, peritoneal dialysis, haemodialysis and transplants;
  • Home nursing, admission to a step-down facility and clinically appropriate rehabilitation;
  • Maternity admissions and confinements;
  • Appliances related to hospital admissions, e.g. leg braces, crutches, etc.
  • Injury on Duty (IOD) cases, which require hospital admission. This ensures that the hospital is aware that the claim will be paid by the Commissioner for Occupational Injuries and Diseases (COID).

How do I pre-authorise?

The entire function is rendered through our call centre, thereby providing ease of access to you, the member. Requests for authorisation can also be requested through SMS. Simply obtain the information required from the doctor that will be treating you in hospital and SMS it, separated by commas, to 45115. E-mail authorisation is also available to certain healthcare funders. Please refer to Call Centre Contact Information.

Details required for SMS: Member number; Patients first name; Hospital name; Doctor’s practice number; ICD 10 Code (get that from the doctor); Procedure name; Date of admission

The cost of the SMS is at normal rates and as soon as the authorisation is loaded, you will receive a return SMS with the authorisation details. In the case of an emergency situation, you or a family member may pre-authorise the admission on the first working day after being admitted. The Scheme will then be responsible for the account based on the scheme’s rules.

What is clinically based evidence (Protocols)?

Pre-authorisation requests are evaluated against protocols developed by considering internationally published medical evidence based information and considering health economic principles and option scheme rules. These protocols considers clinical evidence to ensure that you the patient receive the most appropriate care for your condition, in the most suitable facility at the most cost-effective price.

When do I require pre-authorisation?

For non-emergency admission to hospital, the pre-authorisation must to be completed before admission to hospital, preferably 72 hours before the procedure is to be performed. Emergency admissions may be authorised at the time of admission or the first business day following the admission. You will be provided with an authorisation number and a fax/e-mail copy of the approved authorisation is forwarded to the specified hospital for their records.

Why are second opinions sometimes requested by MSO

For non-emergency spinal and joint replacement surgery for example, it may be necessary to request the opinion of a second medical specialist. The reason for this is to ensure that the surgery is clinically necessary and conservative treatment i.e. physiotherapy is no longer appropriate. An example would be a request for a spinal fusion at multiple levels where no conservative treatment has even been utilised.

Although second opinions are generally only requested to confirm the appropriateness and clinical necessity of a proposed treatment or care, it also confirms a patient’s fitness for surgery. A written evidence-based protocol underpins the decision to request a second opinion and, if indicated, to deny access to benefits.

Why do I need to be fit for surgery?

All schemes have a responsibility to alert members to the fact that their health should be in the most favourable condition before undergoing scheduled elective surgery. Anaesthesia poses a high risk in patients whose cardiac and respiratory fitness is not optimal. Therefore, in these instances, pre-determining fitness for surgery is key to a safe and successful operation and ensuring the best clinical outcome of your planned procedure.

What information do I need when I phone for a pre-authorisation?

  • Membership Number
  • Patient’s name and date of birth
  • Doctor’s name and practice number
  • Name of hospital where the patient will be admitted
  • Procedure to be performed and ICD10 codes
  • Date of admission

What is Case Management?

Case Management, together with the care and supervision of your treating doctor, facilitates optimum treatment for all hospital or related incidents at an appropriate facility and level of care. At the same time, clinical protocols and cost-containment measures are being applied to control the financial risk of members and the Scheme. Only clinically qualified network case managers are utilised, who visit hospitals with the full co-operation of the hospital in all major towns and cities in South Africa.

They will monitor and visit patients with high cost and complicated admissions while the patient is still in hospital to ensure that the member is receiving the most appropriate care in the best possible facility.

What is Disease Management?

Disease management is designed to focus on members who need assistance managing a chronic disease. The program is managed by registered nurses with clinical expertise in disease management, supported by the scheme's internal medical team, who co-ordinate the clinical case needs as well as the program participation of members. Education, self-monitoring and access to medical resources and community information are a focal point of the program. A number of chronic diseases are managed to prevent and control hospital admissions. If you have a known chronic condition it is in your best interest to register on one of the following wellness programs:

  • Diabetes Management Program
  • Asthma Management Program
  • Hypertension Management Program
  • Psychiatry / Mental Wellness Program
  • Oncology Management Program

What are the benefits to you to register?

MSO’s support team will liaise with you regarding your treatment to ensure that you receive the most appropriate and optimum treatment. You will receive guidance and literature on how to live with the disease and will be provided with mechanisms to assist you in the prevention and management thereof.

How do I register on the program?

MSO, in co-operation with your medical aid, will through their data management system, identify those members who will benefit from the programs offered and a clinical consultant will contact you telephonically to register you on the program. You will be given a contact person’s details who you can call when needing further information regarding your disease. Alternatively, to speed up the process, you may also contact MSO to register on the program. Information that can prove helpful to you in managing your disease will be sent directly to your postal address. This includes healthier eating habits, fitness programs and answers to some questions you might have. The Disease Management Call Centre can be contacted on Tel. +27 (0) 11 259 5000, Monday to Friday between 08h00 and 17h00.

MSO will assist you to set and maintain goals for a healthier lifestyle by providing telephone counseling and literature on the management of your specific disease or condition e.g. dietary advice for obese patients with cardiac conditions, advice on effective use of an inhaler for an asthmatic patient, etc.

Co-Payments, limitations and claims submission?

The pre-authorisation service is designed to manage your risk up-front by offering the member a benefit validation and focusing on the potential financial exposure by determining medical appropriateness of the requested treatment or procedure, and whether the cover exists in terms of the member’s benefit policy purchased. A pre-authorisation number is issued based on the information made available to MSO. During the course of your interaction with the applicable MSO call centre agent at the time of making your pre-authorisation, you will be informed whether a co-payment will be applicable to the pre-authorisation. This is based on the Rules of the Medical Scheme and if applicable, you will be informed of your portion of the co-payment at the time of the call. You will also be made aware whether there is a limit applicable to any authorisation for a prosthesis. The payment of the doctor’s account will be subject to available benefits and limits, and paid at rates determined by the specific Scheme.

We strongly advise you to confirm with your doctor and anaesthetist what the total charge will be as there is a possibility that you may be liable for the balance of their account. Please consult your Scheme benefit brochure or contact the Scheme client services department for more information.

With reference to your hospital admission and authorisation, kindly note the following:

  1. Professional service must commence within thirty (30) days of the authorisation date;
  2. The authorisation number must be included on claims submitted;
  3. Claims will be paid at negotiated rates subject to available benefit and the patient being a valid member/dependent of the scheme on the date of   service;
  4. The authorisation number provided is for the hospital account only, the payment of the doctors account will be subject to available benefits and paid at rates determined by your Scheme and benefit option purchased.

All accounts submitted by private, rehabilitation hospitals/unattached operating theatre units/day clinics and sub-acute facilities shall comply with all of the requirements in terms of the Medical Schemes Act No. 131 of 1998. Where possible, such accounts shall also reflect the practice code numbers and names of the surgeon, the anaesthetist and of any assistant surgeon who may have been present during the course of an operation.

The account or statement contemplated in section 59(1) of the Act must contain the following:

  1. The surname and initial of the member;
  2. The surname, first name and other initials, if any, of the patient;
  3. The name of the medical scheme concerned;
  4. The membership number of the member;
  5. The practice code number, group practice number and the individual provider registration number issued by the registering authorities for provider, if applicable, of the supplier of service and, in the case of a group practice, the name of the practitioner who provided the service;
  6. The relevant diagnostic and such other item code numbers that relate to such relevant health service;
  7. The date on which each relevant health service was rendered;
  8. The nature and cost of each relevant health service rendered, including the supply of medicine to the member concerned or to a dependent of that member of the name, quantity and dosage of and new amount payable by the member in respect of the medicine.

All accounts shall be accompanied by a copy of the relevant theatre accounts specifying all details of items charges, as well as the procedures performed. Photocopies of all other documents pertaining to the patients account must be provided on request. Medical aid shall have the right to inspect original source documents at the hospital / attached operating theatre unit concerned. All accounts containing items which are subject to a discount in terms of the recommended benefit shall indicate such items individually and shall show separately he gross amount of the discount.

Hospital Benefit Management

Prescribed Minimum Benefits (PMB’s)
Designated Service Providers (DSP’s)
South African Joint Outcome Study