Last reviewed: November 2026. How we work: our editorial standards, corrections policy and how Curemed is paid. General information, not advice. A personalised recommendation follows a written needs analysis under the FAIS Act.
By Martin Janse van Rensburg, Sales Manager and Financial Advisor at Curemed. Reviewed by Roxanne Hurter-Ehlers, Director of People and Governance.
Medical aid pre-authorisation is the approval your medical scheme issues before a hospital admission, confirming that it has checked the admission against your option benefits, scheme rules and clinical protocols and will fund the authorised hospital stay and procedure. It covers the admission and the procedure codes on the request for the authorised period. It is not a promise to pay every related account: co-payments, benefit limits, separate approvals for scans and shortfalls on specialist accounts can all still apply.
In short
- Pre-authorisation confirms the scheme has checked a planned admission against your option benefits, scheme rules and protocols, and issued a reference number the hospital bills against.
- In an emergency you go to hospital first and notify the scheme afterwards; the law stops a scheme from blocking emergency treatment while authorisation is pending.
- Without authorisation the consequence ranges from a percentage co-payment to full member liability for the hospital account, depending on the scheme.
- An authorisation is not a guarantee of full payment. Specialist shortfalls, co-payments and separate approvals for scans still apply, which is where Gap Cover fits.
What does a medical aid pre-authorisation actually cover?
When you or your doctor request authorisation, the scheme checks the planned admission against your option benefits, its rules and its treatment protocols, then issues a reference number that the hospital uses to bill the scheme directly.
This step is lawful. Regulation 8(4) of the General Regulations under the Medical Schemes Act 131 of 1998 allows schemes to use pre-authorisation, treatment protocols and formularies to manage benefits.
The authorisation covers the hospital admission and the procedure on the request for the authorised period. If the stay runs longer or the procedure changes, schemes generally ask the doctor or hospital to request an extension or an update.
Even with a number in hand, Momentum states that designated service provider (DSP) and benefit-limit co-payments can still apply, and Medshield notes that cover remains subject to scheme rules when the claim is processed. Scheme rules make clear an authorisation is not a promise to pay every cost.
What information does the scheme need before it issues one?
Medshield lists the diagnosis (ICD-10) code, the procedure tariff codes and an estimated length of stay. Your specialist practice usually supplies these, together with the hospital name and admission date.
Bonitas members can request authorisation through the Member App, Member Zone or by phone, and Momentum accepts requests through its app, web chat, WhatsApp or phone. Whichever channel you use, write down the reference number and keep it with your admission papers.
What does a hospital authorisation leave out?
Specialist and anaesthetist accounts are billed separately from the hospital account and may be charged above the scheme rate. The authorisation does not change that, which is where in-hospital shortfalls arise.
Procedure co-payments, non-network hospital penalties and benefit limits also survive the authorisation. Our guide to medical aid co-payments in South Africa explains how each type is applied.
Gap Cover is designed for those in-hospital shortfalls. It is short-term insurance supervised by the FSCA, not a medical scheme benefit, and it pays the difference only once your scheme has paid its portion. The complete guide to Gap Cover in South Africa covers what a policy typically includes.
How do the pre-authorisation rules differ between six schemes in 2026?
Lead times, emergency notification windows and penalties are set by each scheme, and they differ more than many members expect. The table summarises the published 2026 rules at six schemes.
| Scheme | Planned admission | Emergency admission | If you do not get authorisation |
|---|---|---|---|
| Discovery Health Medical Scheme | At least 48 hours before you go in. | Go straight to hospital; notification deadline not published on its public page. | Not published on its public page. |
| Bonitas | Advised at least two days before admission. | Notify within 48 hours of admission, or the first working day after a weekend or public holiday. | Member liable for the full hospital account; no account is paid unless authorisation was obtained. |
| Momentum Medical Scheme | At least 48 hours before admission; for childbirth, contact the scheme within 30 days of the due date. | You, a family member or a friend must contact the scheme within 72 hours of admission. | 30% co-payment on all claims for the event; scheme pays 70% of the negotiated tariff, and only if authorisation would have been granted. |
| Fedhealth | Required for all planned admissions; no lead time stated in the 2026 flexiFED guide. | Within two working days after going to hospital; casualty visits within 48 hours. | Not verified for this article; confirm with the scheme before admission. |
| Bestmed | Advised at least two weeks in advance for planned major operations. | On the first working day after admission. | No benefits granted in a private hospital or day clinic; late authorisations are reviewed against the PMB status of the services. |
| Medshield | No lead time stated; the request needs ICD-10 and tariff codes and an estimated length of stay. | The 2026 MediValue guide gives 48 hours in one section and 72 hours in its emergency section; treat 48 hours as the safe limit. | 20% penalty in addition to option co-payments. |
Three details deserve attention. Medshield gives two different retrospective windows in its 2026 guide, so treat 48 hours as the safe limit and confirm with the scheme. Fedhealth asks you to authorise casualty visits within 48 hours and applies an R880 co-payment per non-PMB casualty visit on its flexiFED options. Bonitas notes in its 2026 BonCore annexure that non-authorised ambulance use is not paid except for PMBs.
What does this look like for a planned knee scope?
Say a member on a Momentum option is booked for a knee arthroscopy on Thursday morning and only phones the scheme on Wednesday afternoon. The 48 hour lead time has already been missed.
If the authorisation is not in place before admission, Momentum applies a 30% co-payment on all claims for the event and pays 70% of the negotiated tariff, and only if authorisation would have been granted in the first place. The same late call on a Bonitas option could leave the member liable for the full hospital account, and Bestmed advises members to request authorisation two weeks ahead for planned major operations.
The practical lesson is simple. Ask at the time of booking whether the practice or you will request authorisation, and diarise a check a week before admission to confirm the reference number exists.
Do you still need authorisation in an emergency?
Not before treatment starts. Regulation 7 of the General Regulations defines an emergency medical condition as the sudden and, at the time, unexpected onset of a health condition that needs immediate medical or surgical treatment, where a failure to treat would result in serious impairment of bodily functions, serious dysfunction of a bodily organ or part, or would place the life of the person in serious jeopardy.
Regulation 8(6) goes further: a scheme may not prohibit a provider from starting appropriate treatment for an emergency medical condition before authorisation is received. The Council for Medical Schemes (CMS) confirms that in an emergency you may go to the nearest facility even if it is not a DSP and, for PMB emergencies, the scheme must pay. Regulation 8(3)(b) also removes co-payments where a non-DSP was used involuntarily, including where immediate treatment for a PMB condition was needed in circumstances or at a location that reasonably precluded using a DSP.
The General Regulations amendment (GN R.1360 of 2002) is published by government, and the CMS keeps a plain-language guide to Prescribed Minimum Benefits.
The duty to notify afterwards still matters. The scheme may ask for confirmation of the diagnosis within a reasonable time, and each scheme sets its own window: 48 hours at Bonitas (or the first working day after a weekend or public holiday), 72 hours at Momentum, two working days at Fedhealth and the first working day after admission at Bestmed.
So if a family member is admitted through casualty on a Saturday night, a call to the scheme on Monday morning keeps you inside each of the published windows above. Leaving it until Wednesday could put you outside several of them.
Do scans and therapy during the stay need their own approval?
Often, yes. Bonitas, Momentum, Fedhealth and Bestmed state that MRI and CT scans need their own pre-authorisation, and Medshield notes that MRI and CT scans done during an admission may need separate pre-authorisation. Momentum adds PET scans and requires a specialist referral, and Bestmed issues an advance reference number for the scan.
In-hospital physiotherapy and occupational therapy need separate authorisation at Momentum, and Fedhealth requires pre-authorisation for in-hospital physiotherapy. If a therapist visits you on the ward, ask the ward clerk whether the scheme has been told.
What can you do if your authorisation is declined?
Ask the scheme for the reason in writing and check it against your option benefits and the PMB status of the condition. Then use the scheme internal dispute process, because the CMS requires you to exhaust it before it will take a complaint.
If the internal outcome does not resolve it, lodge a complaint with the CMS at [email protected], ideally within three years, attaching proof that you escalated to the scheme, together with clinical reports and the accounts. Under section 47 of the Act the scheme gets 30 days to respond. The CMS acknowledges complaints within six working days, aims to finalise within 120 days and fast-tracks clinically urgent cases. The CMS complaints procedure sets out what to include.
If you disagree with the ruling, section 48 lets you appeal to the CMS Appeals Committee by sworn affidavit within three months, at no cost.
How can a Curemed Advisor help before you are admitted?
If the authorisation penalties on your current option worry you, a Curemed Advisor can show how different schemes handle planned and emergency admissions as part of a wider medical aid comparison, and check that your Gap Cover lines up with the way your scheme pays hospital claims.
Getting an authorisation in place before a planned procedure, and chasing it when the scheme gets it wrong, is scheme admin that members usually handle alone on hold to a call centre. CureClub, an exclusive Curemed member benefit, is a dedicated healthcare support team that deals with the medical scheme on your behalf: it helps secure authorisations before procedures, submits and tracks claims, handles chronic medication applications and escalates when the scheme gets something wrong. Over 4,500 people have joined, and it is open to anyone on a registered South African medical scheme, so find out more about CureClub.
Curemed is an FSCA-licensed brokerage (FSP 44098) that has advised South African families since 1992. Talk to a Curemed Advisor before your next planned admission.
Frequently asked questions
Does Gap Cover need its own pre-authorisation?
No separate authorisation is issued by the insurer, but the Gap Cover claim depends on the scheme authorisation. TRA Gap Cover, underwritten by Auto and General Insurance Company, states that you claim once your medical aid has processed and paid its portion, and that Gap Cover pays the difference only where the medical aid has already paid a portion. If the scheme rejects the hospital claim entirely because no authorisation was obtained, Gap Cover generally will not apply either. Our guide on how to claim Gap Cover in South Africa walks through the sequence.
Who can request a pre-authorisation on your behalf?
The member, the treating doctor practice or the hospital can request it, and for emergencies Momentum states that a family member or a friend may contact the scheme within 72 hours. Do not assume someone else has done it: whoever requests it should confirm the reference number with you.
What happens if you go ahead with a planned procedure without an authorisation number?
Hospital admission practice differs, but the scheme consequence does not depend on the hospital. Without an authorisation for a planned procedure, the scheme rules in the table apply, from a 30% co-payment at Momentum to full liability for the hospital account at Bonitas. Confirm the reference number with the hospital at pre-admission. An emergency is different, because Regulation 8(6) prevents the scheme from blocking treatment before authorisation is received.
Does changing your option or scheme affect a pending authorisation?
An authorisation is assessed against the option and scheme rules that apply when it is requested. If you move to a new scheme, it assesses the admission afresh under its own rules and any waiting periods, so ask both schemes in writing before you switch with a procedure pending.
How do Prescribed Minimum Benefits interact with pre-authorisation?
Schemes still ask you to authorise PMB admissions, but PMB status changes what happens when the paperwork is late. Bonitas states that PMBs override benefits and are payable in full, and Bestmed reviews late authorisations against the PMB status of the services. Not every guide says whether its late-authorisation penalty applies to PMB admissions, so ask your scheme directly. Note that PMBs may be excluded during a waiting period for a new applicant who had no medical scheme cover in the preceding 90 days, under section 29A of the Act.
Martin Janse van Rensburg
Sales Manager and Financial Advisor | Curemed Health and Wealth Consultants
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