Healthcare professionals
Anglovaal Group Medical Scheme believes that members and doctors should be free to choose the rate of payment for medical services. When billed using the Scheme Rate, Anglovaal repays claims directly to the healthcare professional. The member gets direct payment for claims billed higher than the Scheme Rate. You can then settle the claim with the doctor.
We constantly engage with the relevant representative bodies to look at ways of enhancing professional relationships to the benefit of both parties. We look to do this without compromising our fundamental principles.
The healthcare funding industry needs to carefully balance the needs of all the key role players - namely healthcare professionals, members and the scheme.
The Scheme participates in the Discovery Health GP and Premier Rate Specialist Direct Payment Arrangements. You can benefit by using healthcare professionals participating in the payment arrangements because the Scheme will cover their approved procedures in full (within the available limits of your relevant benefits). These providers will not charge you for services provided and claims will be paid directly to the providers, which will be convenient for you.
Healthcare professionals who participate in the payment arrangements are also the Designated Service Providers ("DSP") for Prescribed Minimum Benefits and payment will be made as stated. However, if you choose not to use the DSPs, the Scheme will continue to cover the cost of your treatment by such practitioners at up to 100% of the Scheme Rate. You will be responsible for the difference between the amount charged by the healthcare professional and amount paid by the Scheme.
Click here for your In-hospital guide.
Click here for you Out-of-hospital guide.
General practitioners (GP)
A general practitioner or GP is a medical practitioner who gives primary care and specialises in family medicine. A general practitioner treats acute and chronic illnesses and provides preventive care and health education for all. They have particular skills in treating people with multiple health issues.
If your GP sees you out-of-hospital
We pay for GP consultations from your available day-to-day benefits (Medical Savings Account). If your GP participates in the Discovery Health GP Network, he or she will be covered in full, within the available limits of your relevant benefits. You can access the MaPS tool to search for the healthcare professionals who participate in the Discovery payment arrangements.
Medical specialists
A specialty in medicine is a branch of medical science. After completing medical school, physicians or surgeons usually add to their medical education in a specific specialty of medicine by completing a multiple year residency. Medical practitioners who take on a medical specialty are known as medical specialists.
Cover for specialists is according to your Health Plan:
We pay for out of hospital specialist consultations from your available Medical Savings Account, and cover in-hospital consultations from your Hospital Benefits, subject to approval of your hospital admission. If your specialist participates in the Discovery Health payment arrangement, he or she will be covered in full both in- and out-of-hospital. You can access the MaPS tool to search for the healthcare professionals who participate in the Discovery Health payment arrangements.
Dentists
Dentistry is the known evaluation, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity and maxillo-facial area. This includes the adjacent and associated structures and their impact on the human body.
How we cover dentistry
We pay dentistry done out-of-hospital from your Medical Savings Account or Insured Procedure Benefits, subject to available funds and your available dentistry limit.
Approved, defined major maxillo-facial surgery is paid from the Hospital Benefit and isn't limited to the dentistry limit.
Other (allied healthcare professionals)
Allied healthcare professionals are clinical healthcare professionals other than medicine, dentistry, and nursing. They work in a healthcare team to make the healthcare system function.
Cover for allied healthcare professionals is according to your Health Plan:
In-hospital
There is no limit to these healthcare services. We pay up to 100% of the Scheme Rate if you confirmed your admission.
Out-of-hospital
There's no limit to these healthcare services. We pay 100% of the Scheme Rate from your available day-to-day benefits, subject to funds available in your Medical Savings Account.
X-rays
X-rays are photographs or examinations of body parts made by electromagnetic radiation.
The way we pay for x-rays depends on whether you have the x-ray in- or out-of-hospital.
X-rays done in-hospital
We pay for the x-ray from the Hospital Benefit up to a maximum of the Scheme Rate as long as it is related to your confirmed hospital admission.
X-rays done out-of-hospital
We will pay these claims from your Medical Savings Account (MSA), as long as you have money available.
MRI and CT Scans
Who may refer you for a MRI or CT scan
Please Note: All MRI and CT scans must be referred by a specialist
We will only approve scans that have been referred by an appropriate specialist. We will fund MRI or CT scans appropriately referred by a GP during an emergency hospital admission from the Hospital Benefit, subject to benefit confirmation.
How we pay MRI and CT scans needed before planned surgery
If an MRI or CT scan is done as part of a pre-operative work-up for a planned surgical procedure, in other words the scan could have been performed before the admission. We will pay the MRI or CT scan as an out-of-hospital scan.
How we pay MRI and CT scans needed for conservative back and neck treatment
If a MRI or CT scan is needed during an approved admission for a chronic back or neck condition, we will pay the MRI or CT scan as an out-of-hospital scan.
In-hospital
We pay approved MRI and CT scans performed during an approved hospital admission from the Hospital Benefit as long as the scan is related to the reason for the admission.
Out-of-hospital
We pay the account from the Insured Procedures Benefit, up to an annual limit per family per year.
Other Scans
Mammograms
A mammogram is an x-ray examination of the female breast. It uses low-energy x-rays to visualise fine details of breast tissue, particularly the presence of calcification or soft tissue masses. This enables the early diagnosis of breast cancer.
Mammograms done out-of-hospital
We will pay for one mammogram annually from your Screening and Prevention Benefit. You must be referred by an appropriate healthcare professional for the mammogram. We pay for the actual mammogram test from the Screening and Prevention Benefit at 100% of the Scheme Rate. We pay for other related codes and the consultation according to the benefits of your health plan.
Pregnancy scans
Ultrasound imaging allows imaging of the interior of the human body. The advantages of ultrasounds versus x-rays, are that the patient is not submitted to potentially harmful radiation. Images that can't be seen by x-rays are visible through ultrasound imaging.
A maximum of two 2D scans are covered during the pregnancy. Should you require more scans you need to send us a motivation from your doctor. If you have a 3D it will only be paid up to the cost of a 2D scan.
The Scheme will cover these up to the Scheme Rate, and the benefit will not affect your day-to-day benefits, as long as you have registered your pregnancy on the Maternity Programme.
Blood tests
A blood test is any test designed to discover abnormalities in a sample of a person's blood, such as the presence of alcohol, drugs or bacteria or to determine the blood group.
Important note about blood tests
The Scheme does not cover some blood tests (such as the ALCAT test).
The way we pay for blood tests depends on whether you have the blood test in- or out-of-hospital
Blood tests done in-hospital
We pay for the blood tests from the Hospital Benefit up to a maximum of the Scheme Rate as long as it is related to your confirmed hospital admission.
Blood tests done out-of-hospital
We will pay these claims from your Medical Savings Account (MSA), as long as you have funds available.
Endoscopies
What are endoscopies?
Endoscopies - also called scopes - are used to investigate certain medical and surgical conditions such as gastric ulcers, reflux and infections. When we refer to endoscopies and how we cover them, we only refer to four diagnostic endoscopies which include gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy. These are all used to investigate the digestive system. Scopes may also be used to investigate other body systems. All such endoscopies/scopes fall outside of this benefit.
Cover for gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy.
Please Note: Please call us to confirm your benefits at least 48 hours before having this procedure.
Where the scope is performed in your doctor's rooms we refer to this as "out-of-hospital"
Where the scope is performed in hospital, payment for this healthcare service is based on your health plan
In-hospital
In-hospital with authorisation:
Scope codes will be funded from the IPB limit, subject to available scopes IPB limit, related codes/accounts are paid from the Hospital Benefit.
In-hospital without authorisation:
Scope codes will be funded from IPB limit, subject to available scopes IPB limit, all other accounts (Hospital and Related) will be paid from available MSA.
Out-of-hospital?
In doctor's rooms with authorisation:
Scope codes will be funded from your Insured Procedures Benefit (IPB), subject to available scopes IPB limit, all other accounts (hospital and related) will be paid from MSA.
Cover for planned hospital admissions
We cover you in hospital for emergency and planned hospital admissions. In an emergency, go straight to hospital but call us or get someone to call us within 12 hours. For planned hospital admissions, please call us 48 hours before you go to hospital to confirm your admission.
Before you go to hospital for any planned procedure, you must:
- See your doctor
- Call us on 0860 100 693 to confirm your hospital admission at least 48 hours before you go to hospital. If you do not confirm your admission, we will only pay 70% of the costs that we would normally cover.
When you contact us, give us the following details:
- Your membership number
- When you will be admitted to hospital and how long you will stay
- The date of the procedure
- The name of the hospital or clinic
- Your treating doctor's name, practice number and phone number
- Your diagnosis (ask your doctor for the ICD-10 diagnosis code)
- The procedure name
- If one of your dependants is admitted, give us their details.
- There is no overall hospital limit on the Anglovaal Plan.
- Limits apply to some healthcare services and procedures.
Cover is subject to our rules
We pay medically appropriate claims. Your cover is subject to our Scheme rules, funding guidelines and clinical rules. There are some expenses that you may incur while you are in hospital that your benefit does not cover, for example private ward costs. Certain procedures, medicines or new technologies need separate confirmation while you are in hospital.
Cover for Prescribed Minimum Benefits
For Prescribed Minimum Benefits, we pay hospital admissions for a defined list of 271 diagnostic treatment (including HIV) in full at our designated service providers.
How we cover your childbirth
We cover childbirth from your Hospital Benefit, including home births done by midwives with valid practice numbers and who are appropriately registered with the Board of Healthcare Funders. You must authorise the childbirth admission to hospital or home birth with us before you go to hospital. Remember to register your baby with us as soon as possible so we can cover the baby.
There are certain limits for childbirth benefits:
|
Childbirth service |
Limit |
|
Pregnancy scans |
Two 2D scans for each pregnancy, which we pay from the available money in your Medical Savings Account |
|
Normal vaginal deliveries |
A stay of three days and two nights in hospital |
|
Caesarian sections |
A stay of four days and three nights in hospital |
How we cover your healthcare professionals
Your healthcare professionals' accounts are separate from the hospital account. Healthcare professional accounts may include specialist accounts and other related accounts, for example accounts from a surgeon, anaesthetist, pathologist or radiologist.
Healthcare professionals are free to set their own rates.
If your healthcare professional charges the Scheme Rate, we will pay him or her directly. If your healthcare professional charges more than the Scheme Rate, we will pay you. You will have to make sure you pay your healthcare professionals the full amount.
If your healthcare provider is a provider participating in the Discovery Health network, he or she will be covered in full. You can access the MaPS tool to search for the healthcare professionals who participate in the Discovery payment arrangements.
Your benefits
All admissions are subject to prior authorisation
Note: The Scheme's in-hospital clinical protocols will be applied
|
Hospital Benefit |
The limit on this benefit |
|
Admission for a Non-Prescribed Minimum Benefit (Non-PMB) |
|
|
Admission for a Prescribed Minimum Benefit (PMB) |
|
|
Emergency evacuation (road or air) |
|