Co-payments for scopes: How does it work?

If the scope is part of the Prescribed Minimum Benefits (PMB) and you have it in a doctor's room or as part of an authorised hospitalisation, we pay for it from your insured benefits at 100% of the Fund Rate.

If your scope is not part of the PMB, we call it an elective scope. When we talk about a scope in this article, we refer to an elective investigative endoscopy, such as a gastroscopy, colonoscopy, proctoscopy, laparoscopy, sigmoidoscopy, cystoscopy, arthroscopy and hysteroscopy.

You can have a scope in your doctor's rooms or in a hospital. The rules and costs depend on where you have the scope, and if it is part of the Prescribed Minimum Benefits (PMBs) or not.

Where you get the scope matters

If you get the scope in a hospital, you must get authorisation at least 48 hours before the procedure. You must use a hospital, specialists and other medical service providers on the Fund's network list, to get the most from your benefits and minimise co-payments for treatment while in hospital.

We will email the details of the authorisation and any possible exclusions to your treating healthcare professional, the hospital and to you (if we have your email address and you asked for the authorisation).

If you get the scan in your doctor's rooms, you do not need authorisation.

If the scope is part of the PMBs and you have it in a doctor's room or as part of an authorised hospitalisation, we pay for it from your insured benefits at 100% of the Fund Rate.

You must pay a co-payment for elective scopes

If your scope is not part of the PMBs, we call it an elective scope. If you get an elective scope, you must pay a co-payment of R1,330 (for each scope). A co-payment is payment you must make directly to the service provider. If you do not use a doctor or hospital in our network, your co-payment may be much more.

Please visit the Fund's website at www.engenmed.co.za to find a network GP or specialist close to you.