KeyCare Specialist Benefit

1. Mr Jones went to his specialist on the 05th January 2022, he was told he must come back on the 14th February 2022 for another consult. His specialist auth was valid until the 06th February2022. Choose the correct options.

• Member can visit his specialist on the 14th

• Member will require a new authorisation.

• Member must follow the normal specialist referral process to obtain a new authorisation.

• Members GP can request the auth over the phone with the scheme

Hannah is on a Keycare Core plan she needs to be admitted to hospital for a planned procedure. She went to the doctor 3 months ago but was not sure she should do the procedure. She has now decided to do the procedure and wants to know what will she need to do to get a specialist auth no. Choose the correct information we will provide to Hannah.

• Hannah can go to any GP,she will pay for her consult with the GP , the GP will to apply for an auth no by submitting the spec auth application.

• Hannah can ask the specialist to apply for her spec auth

• Hannah can ask the GP she goes to to call preauth and ask us for the auth no

• Hannah must pay her speicalist upfront for the consult, no auth request required.

Mr Govender went to casualty on the 11th January 2022, he was advised he needs to see Dr Craig immediatley. He only has the casualty auth no. Dr Craig’s office is at the hospital on the 2nd floor. While he is waiting at the rooms, he calls the call centre to ask how Dr Craigs consult will be paid. Choose the correct answer.

• We will pay for the consult from the casualty benefit because its within casualty

• We will require a specialist auth no to be requested, then we can pay the consult from the available specialist benefits.

• We will pay the claim from the specialist benefit, no auth will be required as member is going immediatley to the specialist from casualty.

• He will need to go to his doctor for a referral before seeing Dr Craig.

Mr Govender advises he asked Dr Craig’s receptionist how much they will charge and she says Dr is on a payment arrangement. He provides the practice number the consultant sees Dr part of our network {360}. What would the consultant advise Mr Govender.

• We will pay at cost for the consult.

• We will pay at 110% of the Discovery Health Rate.

• We will pay at 100% of the Discovery Health Rate, member will be need to pay the balance to doctor.

• We will pay from specialist benefits at 110% of the Discovery Health Rate.

Mr Smith went to hospital on the 20th December 2021 for an operation. He was discharged on the 22nd December 2021. He was told to come back on the 15th Jan 2022 for a follow up. Will we cover the consult.Choose the correct option .

• We will cover the visit from available specialist benefits, paying at the DH rate.

• We will not pay for the visit because of the global fee for surgical followups.

• We will load an auth for the specialist visit over the phone for the member.

• We will advise member to use his hosiptal auth for the visit.

Mrs Pillay on a Keycare Start plan wants to go to a Surgeon. He Primary Dr Khan advises he will send her to Dr Mike who is linked to the Keycare Start Delivery system. Mrs Pillay is not happy because her friend recommended Dr Arnold to her and she wants to see him. She calls the call centre to ask how her plan covers specialist visits. Choose the incorrect option.

• Mrs Pillay can go to any specialist, we cover the consult from the available two visits upto a rand value of R 2370.

• Mrs Pillay needs to use specialists linked to her delivery system, she will need an authorisation before her visit, her chosen GP must apply for the auth no. we will pay the consult from the available two visits upto a rand value of R 2370 at the DH rate.

• Mrs Pillay can choose the specialist & tell Dr Khan who she prefers, her chosen GP must apply for the auth no. We will pay the consult from the available two visits upto a rand value of R 2370 at the DH rate.

• Mrs Pillay needs to use specialists linked to her delivery system, she will need an authorisation before her visit, her chosen GP must apply for the auth no. we will pay the consult from the available two visits upto a rand value of R 2270 at the DH rate.

Tags

CCSS.RI.1.3

CCSS.RI.1.5

CCSS.RI.2.3

CCSS.RI.K.3

CCSS.RI.K.5

Dr Grey referred Mrs Smith for a bone scan, member has R4000.00 remaining in specialist funds. Her scan will be done on the 15th January2022. He speclist auth is valid until the 16th January2022. Choose the correct option.

• We will not cover the test, its for MOP

• We will pay from day to day benefits no auth required.

• We will pay the claim for the bone scan from the available R 4000.00 at the DH rate. No new auth is required.

• We will pay at cost for the test from available speclist benefits.

Mr Marshal wants to see a specialist, he is on a Keycare Start plan, who can refer Mr Marshall to the specialist. Choose the correct option.

• Primary and Secondary GP

• Primary GP

• Out of area GP

• No referral required

Dr Brown a surgeon wants Mr Blake to go to Dr Khan for for a consult in two weeks from today, Dr Khan is a caridologist. Mr Blake received his specialist authorisation, what does Dr Brown need to do for Mr Blake before he goes to Dr Khan.

• Call the call centre and request an auth no from client services

• Send Mr Blake back to his chosen GP to complete the referral form.

• Calls preauth to request an auth for Dr Khan

• Completes a specialist to specialist referral form.

Mrs Bond went to the dermatologist on the 10th January 2022, Doctor asked her to go for blood tests on the 15th January 2022. She called us to ask is it still ok for her to go for the blood tests. Her specialist auth is valid until the 20th January 2022. She has R 3500.00. What will we advise member.Choose the correct option.

• Confirm R 3500.00 is available, we will pay the test from the the available funds, we will apply the Keycare Formulary to the test claims and member needs to have the test done by the 20th January 2022.

• Confirm the test is covered, we will pay for the test from available specialist funds, confirmed R 3500.00. No formulary would be applied. Member may go at anytime to any pathologist for the test.

• We will pay the test from the available spec amount of R 3500.00, paying at the DH rate. No formulary will be applied to the test claims. Member must have the test by the 20th January2022, as her test must be done within the period her auth is valid for.

• We will pay the claim at cost member must go by the 20th January 2022, we will pay from the available specialist fund.