Hospital pre-authorisation request letter template

Use it for a planned admission, day procedure, scope, scan or specialist treatment that your scheme says needs authorisation. Ask the scheme or your plan's benefit guide what needs it, because the list differs by scheme and plan. Your doctor's rooms or the hospital often apply for you, but you are the one who can check that an authorisation number exists.

Schemes may use pre-authorisation for PMBs as well, so a PMB condition can still need it. Read the pre-authorisation guide for how it works.

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

To: The Pre-authorisation Department
[Scheme name]

Subject: Pre-authorisation request - membership number [MEMBERSHIP NUMBER]

Dear Sir or Madam

Please authorise the following planned admission.

Patient: [NAME AND DEPENDANT CODE]
Procedure: [DESCRIPTION]
ICD-10 code: [ICD-10 CODE]
Tariff or procedure code: [CODE]
Treating doctor: [NAME AND PRACTICE NUMBER]
Hospital: [NAME AND PRACTICE NUMBER]
Planned admission date: [DATE]
Expected length of stay: [NUMBER OF DAYS]
Is this a PMB condition? [YES / NO / PLEASE CONFIRM]

Please confirm in writing:
1. The authorisation number.
2. What the authorisation covers: dates, procedure codes and the doctors and hospital.
3. Any co-payment or penalty that applies, and whether the hospital and doctor are in your network or are DSPs.

Yours faithfully
[Full name]
[Signature]

• The doctor's quote, motivation or referral, showing the procedure and codes.
• The ICD-10 code in the doctor's own words, as the scheme decides largely on the diagnosis.
• For a scan, the doctor's request form.
• For a PMB condition, a line from the doctor saying so, to support the PMB letter.
• Any earlier test results the scheme's protocol asks for.

Put the membership number and patient name on every page.

Email it to the pre-authorisation address on your scheme's website, or call the scheme's authorisation line and follow it up in writing. Save the sent copy, and the authorisation number when it arrives. Ask for the number in writing, not only by SMS or by phone.

Give the number to the hospital's admissions desk before you are admitted, and keep your own copy of the scheme's confirmation.

We found no national deadline for the scheme to decide, so ask for a reply date and apply well before the admission. When the number comes, ask what you will have to pay. Many plans have co-payments on some procedures or a penalty for a non-network hospital. Read your plan's benefit guide and the co-payments and sub-limits guide.

A PMB is paid in full without a co-payment or deductible, but the scheme can still require the DSP, protocols and formulary. Using a non-DSP by choice can cost you a co-payment, but not if the use was involuntary. See designated service providers.

Gap cover is insurance, not a medical scheme. It may pay part of a shortfall or co-payment, depending on the policy. Its annual limit from 1 April 2026 is R226 881.03 per insured person. See gap cover explained.

If authorisation is refused, ask for the reason in writing and use the appeal letter.

In an emergency you may go to the nearest healthcare facility, even if it is not a DSP, and the scheme must cover the costs of an emergency medical condition. The regulations define one as a sudden, unexpected condition that needs immediate treatment to avoid serious impairment of bodily functions or serious danger to life. A scheme may not prohibit a provider from starting an appropriate intervention before authorisation.

Your scheme's rules may still ask you or the hospital to notify it after admission. We could not verify a national notification window, so ask for your scheme's. See emergency and ambulance cover.

• Assuming the hospital or doctor has applied, and not checking.
• Asking too close to the admission date.
• Not asking what co-payment applies before you go in.
• Getting the number by phone and not keeping it in writing.
• Confusing authorisation with a promise to pay everything. It does not remove co-payments or benefit limits.
• Changing the doctor, hospital or procedure after authorisation, without checking the number still applies.