Benefits & claims
Medical aid pre-authorisation explained
By MedicalAidZA editorial team · 4 min read · Updated 29 September 2026
- Needed for
- Planned admissions and many procedures, as your plan lists them
- You receive
- An authorisation number and any co-payment amount
- Emergencies
- Treatment may start before authorisation
- For PMBs
- Schemes may still use pre-authorisation, protocols and formularies
Pre-authorisation is approval you get from your medical aid before a planned hospital admission or certain procedures, confirming the scheme will fund the care and telling you any co-payment. Without it, the scheme can apply a penalty or refuse the claim, even for treatment it would otherwise have paid.
It is one of the easiest ways to avoid a nasty bill. It is also often forgotten in the rush of a hospital booking. In a genuine emergency the rules are different: the law does not let a scheme stop a provider from starting treatment before authorisation.
This guide covers what needs approval, how to get it, the emergency rule, and what to do if you are refused.
What needs pre-authorisation
Your benefit guide lists exactly what needs approval on your plan, and it differs by scheme. Typically you need it for:
- Any planned hospital admission
- Day surgery and many procedures
- Scopes, MRI and CT scans
- Specialised radiology and oncology treatment
When in doubt, call the scheme before the date. Many schemes publish separate hospital authorisation lines, and you can find them in our medical aid contact numbers.
How to get authorised
- Ask your doctor for the procedure and tariff codes and the hospital and admission date.
- Call the scheme, or use its app or email address, with your membership number and those details.
- The scheme gives you an authorisation number and tells you any co-payment.
- Give the number to the hospital when you are admitted, and keep a note of it.
Do this a few days ahead of a planned admission where possible. If the date, hospital or procedure changes, tell the scheme so the authorisation still matches.
For a written request, use our pre-authorisation request letter.
What the authorisation number does and does not do
The number shows the scheme has approved the service under your plan rules. It does not remove co-payments, sub-limits or your remaining benefits, so ask what you will owe before you go in. See co-payments and sub-limits.
Ask, too, whether the doctors, anaesthetist and hospital are on the scheme's network. Authorisation of the admission does not mean every provider will be paid in full. See designated service providers.
Emergencies
In an emergency you do not need to phone first. The Regulations say a scheme may not prohibit, or contract to prohibit, a provider from starting appropriate treatment for an emergency medical condition before receiving authorisation.
The legal definition is a sudden and unexpected onset of a health condition that needs immediate medical or surgical treatment, where failing to treat it would seriously impair bodily functions or organs, or put your life in serious jeopardy. Get treated at the nearest facility, then notify the scheme. Your scheme's rules set the time limit for notification, often a day or two. See emergency and ambulance cover.
Pre-authorisation and PMBs
Prescribed minimum benefits must be paid in full, but the Regulations allow schemes to use pre-authorisation, treatment protocols and formularies to manage them. Skipping a required authorisation on a planned PMB admission can therefore still cost you. See prescribed minimum benefits.
Penalties for skipping it, and what to do if refused
If you skip pre-authorisation on a planned admission, the scheme can apply a penalty, often a percentage of the claim, or decline it. Your scheme's rules set the amount.
If a request is refused:
- Ask for the reason in writing.
- Ask your doctor for a motivation with the clinical reasons.
- Appeal to the scheme, using our appeal a rejected claim letter.
- If it is a PMB, or you think the scheme broke its own rules, use the scheme's dispute process, then the CMS. See how to complain to the CMS.
Frequently asked questions
What is pre-authorisation?
It is approval from your medical aid before a planned hospital admission or certain procedures. The scheme confirms it will fund the care, gives you an authorisation number and tells you any co-payment that applies.
What procedures need pre-authorisation?
Planned admissions, day surgery, scopes, MRI and CT scans and specialised treatments usually do. Your benefit guide lists the exact ones for your plan, so check it or call the scheme.
Do I need pre-authorisation for an emergency?
No. The Regulations do not let a scheme prohibit treatment of an emergency medical condition from starting before authorisation. Get treated at the nearest facility and notify the scheme afterwards.
What happens if I skip pre-authorisation?
The scheme can apply a penalty, often a percentage of the claim, or refuse the claim. Getting the authorisation number before a planned procedure avoids this cost.
How do I get an authorisation number?
Call the scheme, or use its app or email, with your membership number, the procedure and tariff codes, the hospital and the date. The scheme issues the number, which you give to the hospital.
Does an authorisation number guarantee payment in full?
No. It confirms approval under your plan rules, but co-payments, sub-limits and your remaining benefits still apply. Ask the scheme what you will owe before the procedure.
Can a scheme require pre-authorisation for a PMB?
Yes. PMBs must be paid in full, but the Regulations allow schemes to use pre-authorisation, protocols and formularies for them. In an emergency, treatment can start before authorisation.
