FREQUENTLY ASKED QUESTIONS

1) What is a contracted network GP?
A general practitioner as elected by the member

2) What is a Designated Service Provider?
A healthcare provider or group of providers the Scheme has selected as the preferred provider to provide members' diagnosis, treatment and care in respect of one or more PMB conditions.

3) What is a formulary?
A defined list of the Scheme's approved medicine used in the treatment of various diseases.

4) What is a late joiner penalty?
An applicant or dependant of an applicant who, on the date of application, is 35 years or older and has not been a member or a dependant of a medical scheme for a period of five years prior to applying for membership or registration of a dependant, may receive a premium loading that is referred to as a late joiner penalty.

5) What is a non-declaration?
Where a member did not disclose all relevant facts on his health status when joining the Scheme.

6) What is a pre-existing sickness condition?
A condition for which medical advice, diagnosis, care or treatment was recommended or received within the 12 month period ending on the date on which an application for membership was made.

7) What is Underwriting?
Refers to a number of restrictions a medical scheme are allowed - in terms of the Medical Schemes Act - to place on new members and dependants joining.

8) What is Managed Healthcare?
Managed care is defined as the processes and techniques utilized to deliver, administer and assume risk for health services. The aim of this is to control and influence quality, accessibility, utilisation, costs or outcomes of these health services.

9) What Managed Healthcare services are offered by Full Circle Health?
Hospital Benefit Management
Dental Benefit Management
Pharmaceutical Benefit Management
Disease Management
Optical Benefit Management
Provider Networking
Medical Advisory services
Health on Call
Decision support

10) Who can be loaded as Dependants?

DEPENDANT CATEGORIES

Adult dependant:

• Spouse
• Partner
• Immediate family of a member and spouse/partner

Child dependant:

• Natural child
• Step child
• Foster child
• Legally adopted child
• Financially dependant grandchild of member or spouse, under the age of 21.
  • Affidavits or court documentation will be required.
  • Student Certificates are required when older than 21 up to 25 years.
  • No exceptions will be made after 25 years. Should a dependant still be studying after the age of 25 then they will have to apply as individuals should they wish to remain on the scheme.

Special dependant:

• This is extended family members (parent, grandparent, brother, sister) for whom the member is financially liable. Contributions will be that of an adult dependant.
  • Affidavits will be required.
• Mentally and physically handicapped dependants. Contributions will be that of a child dependant.
  • Proof of the dependants condition will be required.
  • No age restriction applies.

11) Can I change my options and when can I change my option?
This can only be done once a year, to be effective on 1 January. During the year, option changes will only be allowed in the case of life changing events such as:

• Marriage
• Death
• Divorce
• Birth of a child
• Involuntary change of Employment (Retrenchment)

12) Where can I post my claims to?
Claims postal address
PATHFINDER Medical Scheme
Private Bag X128
CENTURION
0046

13) Who can I contact when I have a query on my medical plan?
Client Service Centre
Telephone: 0861 147 741

14) When must I submit my claims?
Within 4 months of service date. If submitted after 4 months of date of service the claim will not be paid by the Scheme.