Claim reasons

Not treated as a PMB

The scheme says this service does not fall within the Prescribed Minimum Benefits.

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Words you might see
  • “not a prescribed minimum benefit”
  • “does not qualify as a PMB”
  • “non-PMB”

Questions to ask

  1. Is the service claimed a Prescribed Minimum Benefit, and on what clinical basis was that determined?
  2. Which diagnosis and treatment pair, or Chronic Disease List entry, did the scheme consider when making that determination?
  3. Please provide the clinical protocol the scheme applied in reaching that decision.
  4. Who made the determination, and what are their clinical qualifications?
Details to have ready
  • The diagnosis your treating provider recorded for this service.
  • Whether your provider submitted a motivation or supporting clinical notes.

All claim reasons

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.