PMB application and motivation letter template

Use it when a doctor has diagnosed a condition you think is a PMB and the scheme has not yet confirmed it, or when a PMB claim is being paid from your savings or with a co-payment. For a rejected claim, add the appeal letter. For chronic medicine, use the chronic medication (CDL) letter.

Your plan does not change PMB rights. Even an entry-level hospital plan must cover PMB conditions in full. See the PMB guide.

Ask your doctor to complete the clinical parts or attach a motivation.

[Your full name]
[ID number]
[Membership number]
[Cellphone] | [Email]
[Date]

To: The Clinical / PMB Department
[Scheme name]

Subject: Request to fund a prescribed minimum benefit - membership number [MEMBERSHIP NUMBER]

Dear Sir or Madam

I ask you to confirm that the condition below is a prescribed minimum benefit and to fund it in full.

Patient: [NAME AND DEPENDANT CODE]
Diagnosis: [CONDITION]
ICD-10 code: [ICD-10 CODE]
Date of diagnosis: [DATE]
Treating doctor: [NAME AND PRACTICE NUMBER]
Proposed treatment: [PROCEDURE, MEDICINE OR THERAPY, WITH CODES]
Proposed provider: [PROVIDER, OR PLEASE NAME YOUR DSP FOR THIS CONDITION]

Doctor's motivation: [DIAGNOSIS, SEVERITY AND WHY THIS TREATMENT IS APPROPRIATE, OR SEE ATTACHED].

Under Regulation 8(1) of the Medical Schemes Act regulations, the diagnosis, treatment and care costs of a prescribed minimum benefit condition must be paid in full, without a co-payment or deductible. Please confirm in writing:
1. That this condition is funded as a PMB.
2. Which provider is the DSP, and any protocol, formulary or pre-authorisation I must follow.
3. The authorisation number.

Yours faithfully
[Full name]
[Signature]

Doctor's confirmation: [DOCTOR'S NAME, SIGNATURE AND PRACTICE NUMBER]

• A letter or clinical report from your doctor with the diagnosis and ICD-10 code.
• The quote, script or treatment plan, with tariff or NAPPI codes where the doctor has them.
• Any rejected claim, account or statement that shows how it was paid.
• Test results only if they are needed to show the diagnosis.

The ICD-10 code is the detail that matters most, because PMBs are diagnosis-based. A wrong or missing code on a claim is a common reason for a PMB being treated as an ordinary benefit.

Email the letter to the clinical, pre-authorisation or member services address on your scheme's website. Save the sent email with its date and time, and ask for a reference number. If you phone, note the name, date and reference. If you use the scheme's app or portal, screenshot the confirmation.

Send it before treatment where you can. If the treatment is already under way, send it as soon as the scheme queries the claim.

A scheme's rules may require a designated service provider, and a co-payment may be imposed if you use another provider voluntarily. No co-payment applies if you obtained the service from a non-DSP involuntarily. The regulations treat this as involuntary when:

• the DSP could not provide the service, or not without unreasonable delay;
• immediate treatment was needed in circumstances or places that reasonably stopped you reaching a DSP; or
• there was no DSP within reasonable reach of your home or work.

In an emergency you may go to the nearest healthcare facility even if it is not a DSP, and a scheme may not stop a provider from starting treatment before authorisation. An emergency medical condition is a sudden, unexpected condition needing immediate treatment to avoid serious impairment or danger to life. See designated service providers and emergency cover.

Exclusions do not apply to PMBs. The CMS gives the example of septicaemia after cosmetic surgery: the scheme must fund the septicaemia.

We found no legal deadline for a scheme to answer a PMB request, so ask for a reply date in your letter and follow up in writing. Schemes may apply pre-authorisation, protocols and formularies to PMBs, and waiting periods can matter too. PMB treatment is carved out of the shorter-gap waiting periods, but not out of the waiting period for someone who had no cover for 90 days or more. Confirm your position with the scheme.

If the scheme refuses, ask for the reason in writing, dispute it, and then go to the CMS. The complaint letter has both steps.

The CMS PMB review is still under way. It is costing a proposed primary healthcare package, and schemes were asked for data by 15 October 2026. We found no change to the PMB list, the Diagnosis Treatment Pairs or the Chronic Disease List gazetted by 29 September 2026.

• Sending a letter with no ICD-10 code or doctor's motivation.
• Assuming a PMB means any treatment you like. The scheme can require the DSP, protocols and formulary.
• Choosing a non-DSP by choice and then disputing the co-payment.
• Not asking the scheme in writing who the DSP is.
• Accepting a savings deduction without asking why a PMB was not paid in full.