Claim rejected as not a PMB: what to ask your scheme
Your medical scheme says your claim is not a Prescribed Minimum Benefit. Here is what that means, and the questions to put to the scheme in writing.
The scheme says this service does not fall within the Prescribed Minimum Benefits.
The wording to look for
- “not a prescribed minimum benefit”
- “does not qualify as a PMB”
- “non-PMB”
Questions to put to your scheme in writing
- Is the service claimed a Prescribed Minimum Benefit, and on what clinical basis was that determined?
- Which diagnosis and treatment pair, or Chronic Disease List entry, did the scheme consider when making that determination?
- Please provide the clinical protocol the scheme applied in reaching that decision.
- Who made the determination, and what are their clinical qualifications?
Only you can answer these
- The diagnosis your treating provider recorded for this service.
- Whether your provider submitted a motivation or supporting clinical notes.
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.