Seeing a Specialist

To ensure co-ordinated care, and to minimise unnecessary costs, members should be referred to any specialists by their GP. To create a specialist referral, the GP needs to access the Medscheme interactive voice system to obtain a specialist referral number.

The referral number will apply to either a type of specialist (for example, a dermatologist) or a specific specialist for a period of time that the GP decides on, which can be up to 6 months. The patient still has the choice of which specialist to visit.

There are some exceptions to this rule and members will not need a specialist referral number in the following instances:

  • 1 visit per year to a gynaecologist for a gynaecological check-up and pap smear for female patients
  • 1 visit per year to a urologist for a check-up for male patients
  • Visits to a paediatrician for children under 1 year of age
  • Visits to optical and dental specialists
  • Maternity consultations by a gynaecologist
  • Medical management under the Prescribed Minimum Benefit treatment plan

In case of an emergency, where a patient had to consult a specialist without prior authorisation, a referral number can be obtained after the visit. The patient would need to contact his/her GP to obtain the referral number within 72 hours of the emergency.

Members should remember that obtaining a referral number from a GP is not a guarantee of full payment – specialist consultations will be paid up to the Medical Scheme Rate, or such rate as agreed with the specialist, and subject to available benefits.

Please remember that all members except those on the Platinum and Hospital Network Plans will have a 30% co-payment for consultations with specialists if they were not referred by their GP.

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