Claim rejected for no pre-authorisation: what to ask
Your medical scheme says the service was not authorised before it happened. What that means, and the questions to put to your scheme in writing.
The scheme says it did not authorise the service before it was rendered.
The wording to look for
- “pre-authorisation was not obtained”
- “no authorisation”
- “authorisation was not granted”
Questions to put to your scheme in writing
- What is the scheme’s rule on obtaining authorisation for this service, and where is it published?
- Does the scheme’s rule provide for authorisation after the fact in an emergency, and what does it require?
- Please provide the record of any authorisation request received for this service and the date it was received.
- What penalty was applied for the absence of authorisation, and how was it calculated?
Only you can answer these
- Whether the admission or service was an emergency.
- Whether you or your provider contacted the scheme before or during the service.
Paste your rejection notice and build the letter. It is read on your own device and never uploaded.
See every reason a South African medical scheme gives.
Pryse is not a law firm and does not act for you. Nothing here is a determination of your rights or legal advice, and no registered scheme rule is quoted. The questions ask your scheme to provide its own.