Not a Prescribed Minimum Benefit condition

PMB status turns on the diagnosis code, not the treatment. Compare the ICD-10 code on the claim with the code in your clinical notes — a coding mismatch is a common cause of an incorrect 'not a PMB' finding. Ask the scheme, in writing, which diagnosis code it assessed and on what basis it excluded the condition.

• Ask the scheme, in writing, for the exact rule or code it relied on. A reason code on a statement is not a reasoned decision.
• Check whether the treatment relates to a Prescribed Minimum Benefit. Option rules and annual limits cannot lawfully be used to refuse PMB care.
• Compare the ICD-10 and procedure codes on the account against your clinical notes. Coding mismatches cause a large share of rejections.
• Note the scheme’s internal dispute deadline, and the deadlines for escalating to the Council for Medical Schemes.