What is a PMB?

Are you wondering what the term ‘PMB’ means? The medical aid industry is known for using terms that not everyone is familiar with and as Advisers, we know how overwhelming it can feel! Receiving feedback from your provider filled with fancy words and lengthy codes can really add to the frustration process of claims and Medical Aid queries.

If you’re interested in having an admin support team handle your claims for you, check out more info on our CureClub offering at the bottom of this page.

So, what is a PMB?

Prescribed Minimum Benefits, known as PMBs, are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable. (Council for Medical Schemes,2022)

When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms). (Council for Medical Schemes,2022)

When will a PMB query be relevant to your claim?

  • A PMB query may affect you if you are a member of a medical aid scheme in South Africa and you need to receive medical treatment for one of the conditions or treatments that are defined as a Prescribed Minimum Benefit (PMB) by law.
  • If you are in doubt about whether your medical aid scheme will cover the cost of your treatment, you can ask the scheme for a PMB assessment. This is a process where the medical aid scheme will determine whether the treatment you need is for a PMB condition. If it is, the scheme must cover the cost of the treatment. If it is not, the scheme may decline to cover the cost or may provide coverage under a different benefit structure.

What counts as an emergency medical condition?

  • An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.
  • In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if doctors suspect that the patient suffers from a condition that is covered by PMBs, the medical scheme has to approve treatment. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time. (Council for Medical Schemes,2022)

It is important to note that an emergency medical condition is not limited to physical health, mental health issues like suicidal ideation, or self-harm can also be considered an emergency medical condition.

How our ‘CureClub’ Membership can support you with Claims

This is one of the reasons why we created the CureClub membership. We offer you skilled assistance and advice to manage your new claims or any problematic claims you are dealing with so that you don’t have the stress of doing it yourself.

Some of the perks of joining the Membership:

  • You get a team of claim specialists on your side
  • We process your new claims for you
  • We assist with any existing problematic claims
  • Access to a dedicated team of knowledgeable admin assistants

What will the Membership do for you?

  • Save you hours spent on the phone holding for your medical schemes
  • Save you the confusion of not knowing where your claim is standing
  • We assess each claim individually and go out of our way to ensure they are processed correctly and that any outstanding amounts that could be paid, are paid.
  • Always on your side, we hold the provider liable for claims according to their scheme rules and benefits.

Looking for more info? Click here and one of our friendly Adviser’s will be in touch with you.


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