How to obtain pre-authorisation

For planned admissions and procedures

If you’re being booked into hospital for an operation or other procedure, you’ll need to obtain pre-authorisation from our Member Relations Management (MRM) division prior to the event. From there, our case managers will help you to obtain a pre-quote, and will answer any questions you may have.

Here’s what you need to do

Call us at 021 937 8300 and supply us with the following information: Your membership number The principal member’s name and ID number The patient’s name, date of birth and ID number Date of planned treatment The name of the treating doctor The name of the hospital or other facility The type of procedure or treatment being performed The applicable ICD-10 codes – you will be able to get these from your doctor

What happens next?

Once we have all the necessary information from you, your request will be processed. We will send you confirmation of your pre-authorisation by SMS and letter. An email will also be sent to your doctor, as well as the hospital once they confirm your admission.  These notifications will indicate any costs that will not be covered by CMP. In the event that your doctor’s quoted rate is higher than the CMP tariff, you will be required to sign an acceptance, indicating that you will cover the tariff shortfall.

For emergency admissions

Pre-authorisation is still required in the case of emergency admissions or treatment, and must be requested within 72 hours of the incident. If you cannot contact us yourself, you may ask a friend or family member to act on your behalf. Our case managers will help you to obtain a pre-quote, and will answer any questions you may have.

Here’s what you need to do

Call us at 021 937 8300 and supply us with the following information: Your membership number The principal member’s name and ID number The patient’s name, date of birth and ID number Date of admission or treatment The name of the treating doctor The name of the hospital or facility The type of procedure or treatment being performed The relevant ICD-10 codes – you will be able to get these from your doctor   Note: If you need medical advice about your benefits in an emergency, you can call our medical advisory line at 0860 22 7363.

How we cover emergency treatment

Any treatment that takes place in an emergency room will only be paid for from your insured hospital benefit if you are subsequently admitted to hospital. If hospitalisation is not required, costs will be paid from your Medical Savings Account (MSA). In the case of depleted funds or if you are a HealthPact Premium member, costs will be for your own account.

What happens next?

Once we have all the necessary information from you, your request will be processed. We will send you confirmation of your pre-authorisation by SMS and letter. An email will also be sent to the hospital.  These notifications will indicate any costs that will not be covered by CMP.

What is pre-authorisation?

The pre-authorisation and pre-quote system is our way of ensuring that private hospital costs are managed and covered to your advantage. Pre-authorisation allows us to make sure that the necessary benefits are available, and to be up-front about which costs won’t be covered, and why. This means that you will be properly prepared and informed about the extent of your cover before being admitted. If pre-authorisation is not obtained when required, CMP cannot guarantee the payment of claims.

You need pre-authorisation if you...

have been booked into hospital, either for a planned procedure, or in an emergency have been scheduled for a procedure that would ordinarily require hospitalisation, but is to be performed in a doctor’s rooms need to go for a CT, MRI or Radio Isotope scan require renal dialysis or oncology treatment have been referred to a hospice, or require nursing or step-down services require any additional treatment that was not originally pre-authorised have been diagnosed with a chronic condition and need to obtain chronic medication

Pre-authorisation may be refused if...

your chosen plan does not cover what you’ve requested you have reached your annual benefit limit you or your dependants are still seeing out an initial waiting period you were excluded, on joining, for the condition or procedure in question the procedure you’re requesting is linked to non-disclosure of relevant information on your membership application form CMP’s clinical protocols differ from the benefits on your chosen plan