Pre-authorisation

Pre-authorisation is when the scheme needs to approve certain treatment, procedures, scans, or hospital admissions before they happen. It is a normal part of medical scheme administration and is especially common for planned hospital care and some specialised services.

Clients sometimes hear “pre-authorisation” and assume it means the scheme is trying to be difficult. In reality, it is the scheme’s way of checking that the treatment meets the rules for cover and that the right information has been supplied. According to scheme guidance, details such as the patient’s information, admission date, procedure code, diagnosis code, and provider details may be needed as part of the process.

The important point is this: if pre-authorisation is required and it is not obtained, the claim may not be paid in full. That can become expensive very quickly. Your doctor or hospital may assist with the process, but it is still wise to confirm that it has actually been done. “I thought someone else handled it” is not the strongest strategy when hospital bills are involved.

Why it matters:

• Pre-authorisation is often needed for planned admissions and certain procedures
• The scheme may need clinical and provider details to approve cover
• If it is required and not done, the claim may not be paid in full
• Hospitals and doctors may help, but you should still check
• It is always better to ask before the procedure than to argue after the invoice arrives

At Universal Cover, we believe good broker support and clear financial advice should include helping clients understand important rules like pre-authorisation.