Brokers FAQ

How to write the accreditation tests & How to register an account

What data do you need for a quote?

Company name

Location

Employees’ ID numbers or age and gender

What is a compulsory group?

Compulsory groups:

A minimum of 20 principal insured members.

All members of the group must join.

No waiting periods apply.

What is a voluntary group?

Small / Voluntary groups:

A small group is defined as a group of 2-19 principal insured members.

A voluntary group is where not all members of the group join.

Joining is therefore on an optional basis.

  • 1-month general waiting period
  • 12-month waiting period in respect of chronic medication
  • & optometry benefits 9-month waiting period in respect of maternity benefits

Underwriting restrictions may be removed or altered on request.

What are the waiting periods for individuals?

  • General waiting period
  • 12-month waiting period in respect of chronic medication
  • & optometry benefits 9-month waiting period in respect of maternity benefits

I need a list of network hospitals

Hospital care members have emergency and accident cover at any private hospital.

I need a chronic medication application.

There is no chronic medicine application. Book an appointment with your Unity Health GP.

Your Unity Health GP will register you to collect chronic medication from our network pharmacies.

Do I need to see a nurse before I can see a GP?

Press the ‘please call me button’ on your APP and a case manager based on your symptoms will direct you to a network nurse or GP.

Nurses are consulted for minor ailments and can write scripts up to schedule 2 medicine.

Who are your network specialists?

There is no network of specialists.  Members can consult with their Unity Health GP and get authorisation to see a specialist.

Membership

Membership guide – hospital and primary care

Who should I contact if I have not received my membership card?

Unity Health has gone digital. This means you will receive a digital welcome pack containing a membership certificate, brochure and
cut-out card. A digital version of your membership card is available on the Unity Health App for download. The digital card can be
shared as an image file to all platforms. For assistance, contact Unity health on 0861 366 006

How is cover cancelled?

31 days’ written notice must be provided to Unity Health via e-mail to membership@unityhealth.co.za

Cover is cancelled when premiums are not paid for two consecutive months.

Do I need to nominate a beneficiary to receive my accidental death benefit?

You must complete an accidental death beneficiary form and send it to membership@unityhealth.co.za.
This form is also now included with your application form. You can nominate a beneficiary on the accidental death beneficiary form
or by completing the beneficiary section at application stage.

Where do I obtain a beneficiary nomination form?

Your beneficiary nomination form has been sent to you in the welcome pack.  You can also register and log into the Unity Health web portal where you will have access to all the forms.  Alternatively, call Unity Health’s call centre on 0861 366 006 and one of our friendly call centre agents will forward the form to you.

My contact details have changed, where can I update these details, and should I notify Unity Health?

Please inform your broker of any contact or address changes. You can also contact Unity Health’s call centre on 0861 366 006, e-mail membership@unityhealth.co.za or update this information on your Unity Health App.

It is very important to keep your details upto date so we can effectively communicate with you and to ensure in the case of an emergency that you are assisted as fast as possible.

What types of waiting periods apply to my membership?

Depending on your policy and type of the membership, the following is applicable in terms of waiting periods: Waiting periods apply from the start date of the policy and from each insured person’s cover start date, unless otherwise specified.


GENERAL WAITING PERIOD

Cover does not apply to the Day-to-Day, Wellness Assessments and Preventative Care Benefits during this period.


9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD

Cover does not apply to the Pre-Birth Consultations Benefit during this period.


12 MONTH CHRONIC ILLNESS WAITING PERIOD

Cover does not apply to the Chronic Medication Benefit during this period.


12 MONTH OPTOMETRY WAITING PERIOD

Cover does not apply to the Eye Care Benefit during this period.
Waiting periods do not apply to the Assistance Programme or Emergency Care Benefits.

Premium & Payments

Will my policy premium be adjusted and how frequently will it be adjusted?

Unity Health is rated annually with adjustments taking effect on 1 January of every year, however, we do reserve the right to adjust the premium with 31 days written notice.

Adjustments are based on various factors including but not limited to loss ratio experience, medical tariff increases and inflation, changesin the group demographic profile and benefit changes.

What happens if my employer does not pay premiums on time?

Benefit coverage will be suspended, and any claims submitted during the time of suspension will only be paid once premium payments are up to date. If premiums are not paid for 2 consecutive months and there are no attempts to pay arrear premiums, the policy will be terminated.

My debit order didn’t go through, what should I do?

If you have missed up to 2 premiums, then an EFT payment can be made to activate your policy. For further details on the process contact your broker or contact Unity Health’s call centre on 0861 366 006 or email membership@unityhealth.co.za

What are the dates available for debit orders?

You can choose any of the following dates for our monthly debit order: 15th, 25th and 31st of the month.

Claims

How do claim payments work?

If your Unity Health Network Provider has already sent us your claim, you do not have to send us a copy. If you have paid for the services provided, you can submit it to Unity Health in any of these ways:

E-mail your claim to claims@unityhealth.co.za

Scan and submit your claim via the Unity Health App

Post your claim to – PO Box 1862, Cramerview, 2060

Only benefits payable under this policy will be reimbursed up the the relevant benefit limits. Please read through your policy document thoroughly to avoid disappointment.

 

List of documentation required:

• Principal insured ID

• Bank verification letter not older than three months

• Proof of payment

• Health care and/service provider’s account(s)

How are claims settled?

In most cases, you simply present your Unity Health membership card or digital card and ID to the provider and the provider will submit the claim directly to Unity Health for processing and payment. In isolated cases, if you have paid the provider directly, you may fill out a reimbursement form and e-mail Unity Health at claims@unityhealth.co.za with all supporting documentation within 4 months from the date of treatment. Unity Health will assess and reimburse you in respect of all valid claims.

How do I access information regarding the status of a claim or if I need to search for a service provider?

Unity Health encourages our members to access Unity Health’s online web portal to access the following:

  1. Membership certificate;
  2. The member’s information loaded on Unity Health’s system;
  3. Claims received, processed and paid;
  4. Communication, policy document and brochures.

If you are not registered on Unity Health’s online web portal, please register at https://live.unitywellness.co.za/unitylogin/perslogin.html. If you require more information regarding the use of the online web portal, please contact Unity Health Call Centre on 0861 366 006.

If you wish to dispute a claims assessment, what procedures need to be followed and within what time frame?

A claim may be disputed by:

Making representation to Unity Health or the Insurer indicated in the Disclosure Notice attached to the policy wording within 90 days of receipt of the benefit/rejection letter. Unity Health or the Insurer is obligated to provide you with feedback within 45 days.

You should first aim to resolve the dispute with Unity Health before contacting the Insurer by sending an email to complaints@unityhealth.co.za. You may also contact the Financial Service (FAIS) Ombudsman indicated in the Disclosure Notice attached to the policy wording should you not be satisfied with the response of the Insurer.

The FAIS Ombudsman may also be contacted for any complaints against the broker.

The Ombudsman for Short-Term Insurance may also be contacted for any complaints against the Insurer.

You may also constitute legal action should the matter not be resolved by either the Insurer or the relevant Ombudsman. The claim will prescribe 6 months after the expiry of the 90-days indicated above (no further claims will be payable for the specific claim).

Healthcare Providers

Tips to remember when visiting your GP.

  1. You need to take your Unity Health membership card and either your ID, passport or driving license with you. This will allow your GP to ensure that you are active and do have benefits available.
  2. Always visit a Unity Health Network GP – to check if your provider is on the Unity Health network go to www.unityhealth.co.za or contact the Unity Health call centre at 0861 366 006.
  3. Check with your GP that your treatment or medicine is on our list of covered services.
  4. Ensure your premiums are paid up to date.
  5. For the 10th visit pre-authorisation needs to be obtained.

How do I access a primary health care provider?

  1. Contact the Unity Health call centre on 0861 366 006 for a list of providers close to where you live or work.
  2. Make an appointment with the provider and ensure you present your Unity Health membership card or digital card and ID when you arrive for the consultation.
  3. You may also search for a provider using the Unity Health App or by logging into the member portal where you can search for a provider online.

The Unity Health call centre operates during the following hours:

• Monday to Friday: 08:00 to 17:00 and Saturday: 08:00 to 13:00;
• In the case of emergency after hours call, ER24 on 0861 366 006 and select one for emergencies.

 

What is the difference between a dispensing and non-dispensing provider?

A dispensing provider will provide your medication during the consultation and you will not receive a script to go to the pharmacy. A non-dispensing provider will give you a script during the consultation and you will need to go to an approved pharmacy to collect your medication. Any Alpha Pharm, Clicks, Dischem, Local Choice, Medicare are approved on the Unity Health Network. The script will be subjected to the Mediscor Formulary which your network provider will have.

What if my existing GP is not a network provider?

Call the Unity Health call centre on 0861 366 006 and ask for a provider request form. Fill out the form with your GP’s details and e-mail the form to Unity Health at networks@unityhealth.co.za. Unity Health will contact the GP and advise you whether the GP decided to join or not.

Is there a network provider close to where I live or work?

You have access to the Unity Health website portal. You must register and log in to gain access, to be able to search for a provider close to you via the Unity Health unique GEO mapping tool. This function is also available on the Unity Health mobile application. You can download the App from your play store.

You can also contact Unity Health on 0861 366 006 or e-mail at networks@unityhealth.co.za. Unity Health will forward a list of providers closest to you.

Can a dispensing provider issue a script?

A dispensing provider may issue a script if he/she recommends a medication which is not kept in their rooms.

My dispensing provider did not provide me with enough medication, what do I do?

As per legislation, a consultation is confidential and between a doctor and patient.  The doctor will use his/her discretion on which and how much medication to give and/or prescribe to the patient. It is best to visit your doctor again if the same problem persists.

Do I need to call for authorisation every time I consult with the doctor?

Pre-authorisation would need to be obtained from visit 10 onwards and all authorisations are subject to clinical review. To ensure optimal patient management and care the Underwriting Manager may require pre-authorisation to access benefits in respect of any service provider at any time.

What should I do once I have reached my 10th consultation?

Please contact the Unity Health Call Centre on 0861 366 006 during office hours to request pre-authorisation for 10 or more visits to a GP,
Out-of-Network GP, Nurse, Telemedicine and Intercare Video based GP consultations.

How do nurses’ consultations work?

You can consult with a nurse at approved pharmacy clinics. In many practices, nurses can provide scripts for minor ailments for up to schedule 2 medications.

Is there a limit to nurses’ consultations?

No, but pre-authorisation would need to be obtained from visit 10 onwards for both the nurses’ as well as the GP consultations, and all authorisations are subject to clinical review. Please contact the Unity Health Call Centre on 0861 366 006 during office hours to request pre-authorisation
for 10 or more visits to a GP, Out-of-Network GP, Nurse, Telemedicine and Intercare Video based GP consultations.

How do Telemedicine Consultations work?

Virtual GP consultations are available through approved pharmacies that has a nurse clinic (Alpha Pharm, Clicks, Local Choice, Dischem and
Medicare). If the nurse believes a virtual GP consultation is necessary, the nurse will facilitate the GP consultation through a video conference
link. Pre-authorisation for 10 or more visits to a GP, Out-of-Network GP, Nurse, Telemedicine and Intercare Video based GP consultations.

How does Skype counselling work?

Skype counselling services are provided by registered counsellors who follow specific procedures and clinical protocols. Our partners at Reality Wellness will assist you. Please contact them on one of the following numbers:

Toll free Line: 080 11 22 55 0 WhatsApp: 079 094 7096 Please call me number: 079 094 7096 Email: eppengage@realitywellness.co.za

How do I find an approved pharmacy clinic?

Any Alpha Pharm, Clicks, Dischem, Local Choice, Medicare are approved on the Unity Health Network.

How do I access my dental benefits?

Unity Health has an open network of dentists which means you may consult with any dentist of your choice. Once at the dentist, you must present your membership card or digital card and ID document. The provider is then required to contact the Unity Health call centre on 0861 366 006 for confirmation of member benefits, tariffs and rates.

When can I see a specialist?

If you have visited your Unity Health Network GP and he/she believes that you require the treatment of a specialist, he/she must write a
referral letter, containing proof of failed treatment and send it to riskmanagement@unityhealth.co.za. You will then have to contact the Unity
Health call centre at 0861 366 006 to obtain an authorisation.

How do I request a specialist authorisation?

Members are required to provide the Unity Health case manager with the following information when requesting an authorisation:

  • Name and surname of the member requiring the authorisation
  • Name and practice number of the Specialist your network GP has referred you to
  • Membership number
  • ICD10 code or diagnosis
  • Name and practice number of the referring GP
  • The specialist authorisation provided is valid for two (2) weeks allowing time for you to make an appointment and consult the specialist

You may only visit a specialist if the treatment provided by your GP failed and your GP is of the opinion that you require a specialist’s intervention.

Will tests requested by a Specialist be covered?

Pathology is covered from the specified tests on the Pathology form/those listed in your policy document. We will cover other investigations done by the Specialist in their rooms up to the specialist benefit limit. No other tests, procedures or admission is covered.

Do I need a specific form for pathology / radiology tests referrals?

Yes, please make sure that only the Unity Health pathology/radiology form for tests/referrals are completed and given to you before going for these tests.  All tests not listed on these forms are not covered by Unity Health and will be for the patient’s account. The correct forms are available on the web portal.

Accidents, emergencies and other benefits

What is an emergency?

An “emergency” is an event of a sudden, and at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or would place the person’s life in jeopardy. Examples include heart attacks and strokes.

What is an accident?

“Accident” means bodily injury caused by violent accidental and external physical means. Examples include motor vehicle accidents, severe burns, exposure to poisons.

What do I do in the event of a medical emergency or a serious accident?

  1. Call Unity Health call centre on 0861 366 006 and press 1 for an emergency, or make use of the push-to-call function on your Unity Health App.
  2. Ask to speak to the Case Manager on duty.
  3. ER24 will verify the membership of the person in need of help, whether it be the main member or a dependant.
  4. ER24 will assist the member with advice and emergency transportation to the nearest inpatient hospital facility.
  5. Authorisation is required from a Unity Health Case Manager before member treatment.
  6. Unity Health will received the account which will be subject to clinical review, based on clinical information from the hospital, before being processed.

What is an emergency casualty department?

An emergency department, also known as an accident and emergency department, emergency room (ER) or casualty department, is a medical treatment facility specialising in emergency treatment of patients who arrive without a prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care centres. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a wide range of illnesses and injuries, some of which may be life-threatening and require immediate medical attention.

What does emergency stabilisation mean?

A benefit equal to the cost of inpatient hospital treatment in a hospital emergency or casualty unit provided that such treatment is in the event of an emergency. Stabilisation for the medical condition, e.g. appendicitis in the emergency unit would be covered under the stabilisation benefit, but admission to hospital for surgery would not be covered. In terms of your policy, it is the immediate treatment administered to a person in an emergency, to stabilise the patient before they are transferred to a state facility for further management.

Is the cost of the ambulance service covered?

Yes, you can contact ER24, the designated provider on Unity Health call centre on 0861 366 006 in the event of an emergency or serious accident. Once you have been transported to the closest appropriate facility, the hospital should contact Unity Health.

Is the member covered for overseas travel?

No, international cover is not provided.

What do I do if a benefit requires pre-authorisation?

You should contact the Unity Health call centre on 0861 366 006 and select the option for pre-authorisations. To access the benefit, you will require a pre-authorisation number from Unity Health.

Do I need an authorisation for maternity benefits?

Yes. Once the member has selected their network GP or gynecologist the member or provider should contact Unity Health call centre and request to speak to the Unity Health Case Manager for pre-authorisation of their consultations and pregnancy ultrasounds.

What is a chronic condition?

This is a disease that lasts 3 months or more and generally cannot be prevented by vaccines or cured by medication, nor do they just disappear. A chronic disease can be treated by medication that will be required to be taken for a lifetime.

For example: Asthma; Chronic Obstructive Pulmonary Disorder; Diabetes Type 1&2; Epilepsy; HIV/AIDS; Hyperlipidaemia; Hypertension; Tuberculosis

What do I do if I suspect I have COVID-19?

1. Do not panic, we will guide you through the entire process.

2. Self-quarantine, isolate yourself.

3. Phone Unity Health on 0861 366 006 and ask to speak to one of our Case managers

4. Our Case Managers will ask you a series of questions, provide you with information and guide you on what to do next.

Are COVID-19 tests covered?

You have access to a COVID-19 PCR pathology test should you test positive for COVID-19. Authorisation and referral by a network GP are required. Upfront payment will be required, in which case we will reimburse you if your test result is positive. Contact our Call Centre on 0861 366 006 and ask to speak to one of our Case Managers to obtain pre-authorisation. You may visit any Ampath, Pathcare or Lancet laboratory.

What other support does Unity Health offer under COVID-19?

Members on primary healthcare options have access to COVID-19 benefits.
If a test shows you have contracted COVID-19 and you visit a Unity Health Network GP, our benefits include the following:

Consultation with a Unity Health Network GP

Consultation with a Unity Health Network Nurse The test that shows you have COVID-19 (diagnostic testing – only if the test is positive)

Basic chest X-rays

Acute medication available on the formulary

We have experienced Case Managers available 24/7 to assist with:
GP consultations

Nurse consultations

Testing guidelines

COVID-19 information and guidelines.Our partners at Reality Wellness are available to assist at any point in the process to help you cope with uncertainty, changes and challenges. Skype sessions are available for counselling.

What is an exclusion?

Refers to the list of services, conditions or events as per below, which are always excluded from cover.

1. Nuclear weapons or nuclear material or by ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any self-sustaining process of nuclear fission;

2. Investigations, treatment or surgery for obesity or its sequel or cosmetic surgery or surgery directly or indirectly caused by or related to or in consequence of cosmetic surgery other than as a result of an Insured Incident;

3. Suicide, attempted suicide or self-inflicted injuries unless such injuries are sustained to preserve another human life;

4. Routine physical or any other procedure of a purely diagnostic nature or any other examination where there are no objective indications of impairment in normal health and laboratory diagnostic or x-ray examinations except in the course of a medical condition or disability established by prior call or attendance of a Medical Practitioner;

5. All costs which are in the opinion of the Underwriting Manager’s clinical review team: a. Not medically necessary or clinically appropriate or do not meet the healthcare needs of the Insured Person; b. Not consistent in type, frequency and duration of treatment;

6. Procedures performed in doctors’ rooms that are not listed in the list of tariff code descriptions;

7. Any accident where the initial accident event occurred prior to the Insured Person’s commencement date with this policy;

8. The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a registered Medical Practitioner (other than the Insured Person) or any illness caused using alcohol;

9. Any medical transportation service for non-emergency purposes;

10. Drug addiction;

11. The supply of medication that is not listed on the Underwriting Manager’s formulary list;

12. An event directly attributable to the Insured Person having an alcohol content exceeding zero point zero five (0.05) grams per one hundred (100) millilitres of blood or the Insured Person suffering from alcoholism;

13. Artificial insemination, infertility treatment or contraceptive;

14. Robotic surgery, specialised mechanical or computerised appliances equipment or all related Service Providers;

15. Contact lenses;

16. Participation in: a. Active military duty, police duty or police reservist duty; b. Aviation other than as a passenger; c. Any Competitive or Professional Sport or Activity; d. Any form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle vessel craft or aircraft);

17. External prosthesis or appliances such as artificial limbs;

18. Any activity prohibited by law;

19. Any benefit requiring pre-authorisation where no authorisation was requested or approved.

20. More than one General Practitioner, nurse or virtual General Practitioner consultation on the same day for the same Insured Person.

Medications

What is acute medication?

Acute medication is used for diseases or conditions that have a rapid onset, severe symptoms, and that requires a short course of medicinal treatment. Acute medication must be prescribed by a Unity Health contracted network GP. Only medication on the Unity Health acute medicine formulary will be covered. Acute medication will be provided as part of the acute consultation (when dispensed by a dispensing GP) or by a Unity Health network pharmacy if prescribed by a non-dispensing GP.

What is chronic medication?

It is medicine prescribed by a medical practitioner for an uninterrupted period longer than three (3) months. This medicine is used for a medical condition which forms part of an approved list of chronic conditions.

For example: Asthma; Chronic Obstructive Pulmonary Disorder; Diabetes Type 1&2; Epilepsy; HIV/AIDS; Hyperlipidaemia; Hypertension; Tuberculosis

What is a formulary?

A formulary is an approved list of medication that has been approved by Unity Health.  The member can normally find both generic and brand name drugs in formularies.  Formulary prescription medication is chosen for its cost, effectiveness and safety.  Non-formulary drugs will be for the member’s own cost.

Can I buy medication over the counter (OTC) without a script from a GP?

No, you can only get medication from a pharmacy with a script from a non-dispensing Unity Health network GP. You may consult with a nurse at an approved pharmacy and he/she can supply a script for minor ailments.

Will medication prescribed by a Specialist be paid?

We will cover the specialist consultation up to the benefit limit. If there are funds remaining, non-formulary medication may be paid from the specialist benefit. If the medication is on the acute formulary, it will be covered from the acute medication benefit. For chronic medication, the first script from a Specialist will/can be used for registering on the Disease Management Program. The subsequent scripts will need to be done by a network GP.

What is the process for applying for chronic medication?

  1. You must consult with your Network GP who will prescribe your chronic medication accordingly (existing or new chronic conditions).
  1. The Network GP will assist you by one of the following methods:
  2. The Network GP can contact Chroniline on 0860 119 553 to obtain telephonic authorisation on behalf of the patient.
  3. The Network GP can fax a copy of the prescription to 0866 151 509 with the member’s details reflecting on the script.
  4. The Network GP can e-mail a copy of the prescription to preauth@mediscor.co.za

Where can I collect my medication?

Once your chronic medication has been approved, you may collect it from any approved pharmacy including, Alpha Pharm, Clicks, Dischem, Local Choice, Medicare . Remember your prescription and membership card or digital card.

Can my chronic medications be delivered?

Once you are registered to get chronic medication you have an option for your medications to be delivered by our courier pharmacy (MediLogistics) Your medications can be delivered to

  • To your network GP
  • To your home physical address
  • To your work physical address

 

Email your prescription with your preferred delivery address to: medipost@unityhealth.co.za.

Do I need to pay for the delivery?

Deliveries are usually free of charge.

UNIbot

Who is UNIBot?

UNIBot is very helpful and can assist with most general queries, FAQ’s and form requests from new clients,
Unity Health members, providers, brokers and companies. Below is a list of what UNIbot can assist you
with. UNIBot can be accessed on our website, www.unityhealth.co.za

List of what UNIbot can assist with:

Queries:

Request a call back

General queries

Claims queries (new or existing)

Finding a network provider

Authorisation

FAQ’s

Forms:

Pathology form

Radiology form

The Unity Health Mobile Application

The Unity Health App offers useful features such as:

An emergency button for easy emergency assistance;

Tracking your GP visits, medication, and other claims;

Finding your closest GP, dentists or optometrist;

Your digital membership card with your membership details;

A useful summary of your plan details, benefits and limits;

Your personal details;

All contact details for any enquiries;

FAQ’s

Access to the intercare benefit