Tests and scans

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What are tests and scans?

Tests and scans involve any investigative procedures that are undertaken to identify and diagnose medical conditions that would not normally be detected with the naked eye.

Depending on your plan type, Discovery Health Medical Scheme provides cover for in- and out-of-hospital tests and scans, including investigations, radiology, blood tests, MRI and CT scans.

Cover for investigations

We cover endoscopies such as gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system.

Admissions for scopes

Depending on where you have your scope done we pay the following amount from your available day-to-day benefits and the balance of the hospital and related accounts from your Hospital Benefit. If you do not have enough funds available in your day-to-day benefits, you will need to pay this amount.

Upfront payments for scope admissions:

Day clinic account Hospital account
R3 650 R5 300, this co-payment will reduce to R4 550 if performed by a doctor who is part of the Scheme's value-based network
If both a gastroscopy and colonoscopy are performed in the same admission
R4 450 R6 600, this co-payment will reduce to R5 650 if performed by a doctor who is part of the Scheme's value-based network

No upfront payment applies:

If scopes are performed in the doctor?s rooms, as part of a confirmed Prescribed Minimum Benefits (PMB) condition, or the patient is under the age of 12, you will not have to pay any amount upfront. We pay the account from the Hospital Benefit.

DOWNLOAD THE COVER FOR DIAGNOSTIC ENDOSCOPIES BENEFIT GUIDE

Cover for radiology

X-rays can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital radiology expenses from your available day-to-day benefits.

Cover for MRI/CT Scans

Scans are covered from your Hospital Benefit. Depending on the circumstances, you may be liable for an upfront deductible. Note that only a specialist or trauma unit GP in our network may refer you for a MRI or CT scan.

We pay for scans as an out-of-hospital expense if:

  • A scan is done as part of a pre-operative work-up for a planned surgical procedure.
  • A scan is needed for conservative back and neck treatment during an approved admission. Specific rules and limits apply to conservative back and neck scans.

Scans done as part of an approved admission

We pay up to the Discovery Health Rate (DHR) from your Hospital Benefit if the scan is related to your hospital admission.

Other scans

If it is not related to your admission or for conservative back and neck treatment, we pay of the first R3 130 from your available day-to-day benefits and the balance from your Hospital Benefit, up to the Discovery Health Rate. For conservative back and neck scans a limit of one scan per spinal and neck region applies.

Cover for pathology

Pathology can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital radiology expenses from your available day-to-day benefits.

Cover for investigations

We cover endoscopies such as gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system.

Admissions for scopes

Depending on where you have your scope done we pay the following amount from your available day-to-day benefits and the balance of the hospital and related accounts from your Hospital Benefit. If you do not have enough funds available in your day-to-day benefits, you will need to pay this amount. If you are on the Classic Smart Comprehensive Plan you will have to pay this amount until you reach your Annual Threshold.

Upfront payments for scope admissions:

  Day clinic account Hospital account
Classic, Essential, Classic Smart and Delta options R3 650 R5 300, this co-payment will reduce to R4 550 if performed by a doctor who is part of the Scheme's value-based network
If both a gastroscopy and colonoscopy are performed in the same admission
Classic, Essential, Classic Smart and Delta options R4 450 R6 600, this co-payment will reduce to R5 650 if performed by a doctor who is part of the Scheme's value-based network

Upfront payments for scopes performed outside of the Day Surgery Network:

For Classic and Essential plans, an upfront payment of R5 700 will apply.

Where both a gastroscopy and colonscopy are performed the higher upfront payment of R6 600 will apply.

For Delta options, an upfront payment of R8 700 will apply.

For Classic Smart, an upfront payment of R9 950 will apply.

No upfront payment applies:

If scopes are performed in the doctor?s rooms, as part of a confirmed Prescribed Minimum Benefits (PMB) condition, or the patient is under the age of 12, you will not have to pay any amount upfront. We pay the account from the Hospital Benefit.

DOWNLOAD THE COVER FOR DIAGNOSTIC ENDOSCOPIES BENEFIT GUIDE

Cover for radiology

X-rays can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital radiology expenses from your available day-to-day benefits.

On Classic Smart Comprehensive, we pay specialist-referred radiology at the Discovery Health rate, up to the Specialist Benefit limit. Out-of-hospital radiology is paid from your Above Threshold Benefit once you reach your Annual Threshold.

Cover for MRI/CT Scans

Scans are covered from your Hospital Benefit. Depending on the circumstances, you may be liable for an upfront deductible. Note that only a specialist or trauma unit GP in our network may refer you for a MRI or CT scan.

We pay for scans as an out-of-hospital expense if:

  • A scan is done as part of a pre-operative work-up for a planned surgical procedure.
  • A scan is needed for conservative back and neck treatment during an approved admission. Specific rules and limits apply to conservative back and neck scans.

Scans done as part of an approved admission

We pay up to the Discovery Health Rate (DHR) from your Hospital Benefit if the scan is related to your hospital admission.

Other scans

If it is not related to your admission or for conservative back and neck treatment, we of the first R3 130 from your available day-to-day benefits and the balance from your Hospital Benefit, up to the Discovery Health Rate. For conservative back and neck scans a limit of one scan per spinal and neck region applies.

On Classic Smart Comprehensive, if not related to your hospital admission, you pay of the first R3 130 for your MRI or CT scan until you reach the Annual Threshold. We cover the balance of the scan from your Hospital Benefit, up to the DHR.

Cover for pathology

Pathology can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital radiology expenses from your available day-to-day benefits.

On Classic Smart Comprehensive, we pay specialist-referred radiology at the Discovery Health rate, up to the Specialist Benefit limit. Out-of-hospital radiology is paid from your Above Threshold Benefit once you reach your Annual Threshold.

Cover for investigations

We cover endoscopies such as gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system.

Admissions for scopes

Depending on where you have your scope done, you will have to pay the following amount, and we will pay the balance of the hospital and related accounts from your Hospital Benefit.

Upfront payments for scope admissions:

  Day clinic account Hospital account
Classic, Essential, Classic Smart and Delta options R3 650 R5 900, this co-payment will reduce to R5 150 if performed by a doctor who is part of the Scheme's value-based network
If both a gastroscopy and colonoscopy are performed in the same admission
Classic, Essential, Classic Smart and Delta options R4 450 R7 350, this co-payment will reduce to R6 400 if performed by a doctor who is part of the Scheme's value-based network

Upfront payments for scopes performed outside of the Day Surgery Network:

Where a scope is performed in a facility outside of the Day Surgery Network an upfront payment of R5 700 will apply, except if performed in a hospital outside the Day Surgery Network where an upfront payment of R5 900 will apply.

Where both a gastroscopy and colonoscopy are performed the upfront payment of R7 350 will apply.

No upfront payment applies:

If scopes are performed in the doctor?s rooms, as part of a confirmed Prescribed Minimum Benefits (PMB) condition, or the patient is under the age of 12, you will not have to pay any amount upfront. We pay the account from the Hospital Benefit.

DOWNLOAD THE COVER FOR DIAGNOSTIC ENDOSCOPIES BENEFIT GUIDE

Cover for radiology

X-rays can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital radiology expenses from your available day-to-day benefits.

Cover for MRI/CT Scans

Scans are covered from your Hospital Benefit. Depending on the circumstances, you may be liable for an upfront deductible. Note that only a specialist or trauma unit GP in our network may refer you for a MRI or CT scan.

We pay for scans as an out-of-hospital expense if:

  • A scan is done as part of a pre-operative work-up for a planned surgical procedure.
  • A scan is needed for conservative back and neck treatment during an approved admission. Specific rules and limits apply to conservative back and neck scans.

Scans done as part of an approved admission

We pay up to the Discovery Health Rate (DHR) from your Hospital Benefit if the scan is related to your hospital admission.

Other scans

If it is not related to your admission or for conservative back and neck treatment, we pay of the first R3 130 from your available day-to-day benefits and the balance from your Hospital Benefit, up to the Discovery Health Rate. For conservative back and neck scans, you must also pay the first R3 850 of the hospital account. We pay the balance of the scan from the Hospital Benefit up to 100% of the Discovery Health Rate. A limit of one scan per spinal and neck region applies for conservative back and neck scans.

Cover for pathology

Pathology can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital radiology expenses from your available day-to-day benefits.

Cover for investigations

We cover endoscopies such as gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system.

Admissions for scopes

Depending on where you have your scope done we pay the following amount from your available day-to-day benefits and the balance of the hospital and related accounts from your Hospital Benefit. If you do not have enough funds available in your Medical Savings Account (MSA), you will need to pay this amount.

Upfront payments for scope admissions:

  Day clinic account Hospital account
Classic, Essential, Classic Smart and Delta options R3 650 R6 250, this co-payment will reduce to R5 500 if performed by a doctor who is part of the Scheme's value-based network
If both a gastroscopy and colonoscopy are performed in the same admission
Classic, Essential, Classic Smart and Delta options R4 450 R7 800, this co-payment will reduce to R6 850 if performed by a doctor who is part of the Scheme's value-based network

Upfront payments for scopes performed outside of the Day Surgery Network:

Where a scope is performed in a facility outside of the Day Surgery Network an upfront payment of R5 700 will apply, except if performed in a hospital outside the Day Surgery Network where an upfront payment of R6 250 will apply. Where both a gastroscopy and colonoscopy are performed the upfront payment of R7 800 will apply. For Delta options, the out-of-network upfront payment of R8 700 will apply.

No upfront payment applies:

If scopes are performed in the doctor?s rooms, as part of a confirmed Prescribed Minimum Benefits (PMB) condition, or the patient is under the age of 12, you will not have to pay any amount upfront. We pay the account from the Hospital Benefit.

DOWNLOAD THE COVER FOR DIAGNOSTIC ENDOSCOPIES BENEFIT GUIDE

Cover for radiology

X-rays can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital radiology expenses from your available funds in your Medical Savings Account.

Cover for MRI/CT Scans

Scans are covered from your Hospital Benefit. Depending on the circumstances, you may be liable for an upfront deductible. Note that only a specialist or trauma unit GP in our network may refer you for a MRI or CT scan.

We pay for scans as an out-of-hospital expense if:

  • A scan is done as part of a pre-operative work-up for a planned surgical procedure.
  • A scan is needed for conservative back and neck treatment during an approved admission. Specific rules and limits apply to conservative back and neck scans.

Scans done as part of an approved admission

We pay up to the Discovery Health Rate (DHR) from your Hospital Benefit if the scan is related to your hospital admission.

Other scans

If it is not related to your admission or for conservative back and neck treatment, we pay the first R3 130 from your available day-to-day benefits and the balance from your Hospital Benefit, up to the Discovery Health Rate (DHR). Limited to one scan per spinal and neck region.

Cover for pathology

Pathology can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for out-of-hospital pathology expenses from your available funds in your Medical Savings Account.

Cover for investigations

We cover endoscopies such as gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system.

Admissions for scopes

Depending on where you have your scope done, you have to pay the following amount and we pay the balance of the hospital and related accounts from your Hospital Benefit.

Upfront payments for scope admissions:

  Day clinic account Hospital account
Classic, Essential, Classic Smart and Delta options R3 650 R6 250, this co-payment will reduce to R5 500 if performed by a doctor who is part of the Scheme's value-based network
If both a gastroscopy and colonoscopy are performed in the same admission
Classic, Essential, Classic Smart and Delta options R4 450 R7 800, this co-payment will reduce to R6 850 if performed by a doctor who is part of the Scheme's value-based network

Upfront payments for scopes performed outside of the Day Surgery Network:

Where a scope is performed in a facility outside of the Day Surgery Network, an upfront payment of R9 950 will apply.

No upfront payment applies:

If scopes are performed in the doctor?s rooms, as part of a confirmed Prescribed Minimum Benefits (PMB) condition, or the patient is under the age of 12, you will not have to pay any amount upfront. We pay the account from the Hospital Benefit.

DOWNLOAD THE COVER FOR DIAGNOSTIC ENDOSCOPIES BENEFIT GUIDE

Cover for radiology

X-rays can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

You need to pay for out-of-hospital radiology expenses.

Cover for MRI/CT Scans

Scans are covered from your Hospital Benefit. Depending on the circumstances, you may be liable for an upfront deductible. Note that only a specialist or trauma unit GP in our network may refer you for a MRI or CT scan.

We pay for scans as an out-of-hospital expense if:

  • A scan is done as part of a pre-operative work-up for a planned surgical procedure.
  • A scan is needed for conservative back and neck treatment during an approved admission. Specific rules and limits apply to conservative back and neck scans.

Scans done as part of an approved admission

We pay up to the Discovery Health Rate (DHR) from your Hospital Benefit if the scan is related to your hospital admission.

Other scans

Classic: if not related to your admission or for conservative back and neck treatment, you will have to pay the first R3 130 and the balance will be paid from the Hospital Benefit up to the Discovery Health Rate (DHR). For conservative back and neck scans a limit of one scan per spinal and neck region applies.

Essential: You will have to pay if not related to your admission or if for conservative back and neck treatment.

Cover for pathology

Pathology can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

You need to pay for out-of-hospital pathology expenses.

Cover for investigations

We cover endoscopies such as gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system.

Admissions for scopes

Depending on where you have your scope done, you have to pay an upfront amount and we pay the balance of the hospital and related accounts from your Hospital Benefit.

Upfront payments for scope admissions:

  Day clinic account Hospital account
Classic, Essential, Classic Smart and Delta options R3 650 R6 250, this co-payment will reduce to R5 500 if performed by a doctor who is part of the Scheme's value-based network
If both a gastroscopy and colonoscopy are performed in the same admission
Classic, Essential, Classic Smart and Delta options R4 450 R7 800, this co-payment will reduce to R6 850 if performed by a doctor who is part of the Scheme's value-based network

Upfront payments for scopes performed outside of the Day Surgery Network:

Where a scope is performed in a facility outside of the Day Surgery Network an upfront payment of R5 700 will apply, except if performed in a hospital outside the Day Surgery Network where an upfront payment of R6 250 will apply. Where both a gastroscopy and colonoscopy are performed the upfront payment of R7 800 will apply. For Delta options, an upfront payment of R8 700 will apply.

No upfront payment applies:

If scopes are performed in the doctor?s rooms, as part of a confirmed Prescribed Minimum Benefits (PMB) condition, or the patient is under the age of 12, you will not have to pay any amount upfront. We pay the account from the Hospital Benefit.

DOWNLOAD THE COVER FOR DIAGNOSTIC ENDOSCOPIES BENEFIT GUIDE

Cover for radiology

X-rays can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

You need to pay for out-of-hospital radiology expenses.

Cover for MRI/CT Scans

Scans are covered from your Hospital Benefit. Depending on the circumstances, you may be liable for an upfront deductible. Note that only a specialist or trauma unit GP in our network may refer you for a MRI or CT scan.

Scans done as part of an approved admission

We pay up to the Discovery Health Rate (DHR) from your Hospital Benefit if the scan is related to your hospital admission.

Other scans

If it is not related to your admission, or for conservative back and neck treatment, we do not pay for it.

Cover for pathology

Pathology can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

You need to pay for out-of-hospital pathology expenses.

Cover for investigations

We cover endoscopies such as gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system.

  • You have Prescribed Minimum Benefit (PMB) cover in the KeyCare Day Surgery Network (or KeyCare Start Day Surgery Network for KeyCare Start members).
  • Authorised scopes done in the doctor's rooms will be covered from your Hospital Benefit.

DOWNLOAD THE COVER FOR DIAGNOSTIC ENDOSCOPIES BENEFIT GUIDE

Cover for radiology

X-rays can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

On KeyCare Plus and KeyCare Start, we pay for a list of basic X-rays at a network provider. Your chosen GP must ask for the X-rays to be done.

Out-of-hospital radiology expenses are not covered on the KeyCare Core plan.

Cover for MRI/CT Scans

Scans are covered from your Hospital Benefit. Depending on the circumstances, you may be liable for an upfront deductible.

We pay for scans as an out-of-hospital expense if:

  • A scan is done as part of a pre-operative work-up for a planned surgical procedure.
  • A scan is needed for conservative back and neck treatment during an approved admission. Specific rules and limits apply to conservative back and neck scans.

Scans done as part of an approved admission.

We pay your accounts up to a maximum of the Discovery Health Rate for approved hospital admissions at a network hospital.

Other scans

Specialist cover up to R4 530 on KeyCare Plus and KeyCare Core, and up to two visits up to R2 270 on KeyCare Start per person per year. Your chosen GP must refer you to a specialist and you need a reference number from us before your consultation with the specialist. On KeyCare Plus, if you need to see a maxillo-facial surgeon, periodontist, ophthalmologist or a specialist for maternity care, you do not need a referral from your GP or a reference number from us. Out-of-hospital MRI and CT scans are paid up to the Specialist Benefit limit.Please note that there is no benefit for MRI and CT scans related to conservative back or neck treatment on the KeyCare plans.

Cover for pathology

Pathology can be done either in-hospital as part of a planned admission or out-of-hospital as part of your day-to-day benefits.

In-hospital

We cover up to the Discovery Health Rate (100%).

Out-of-hospital

We pay for a list of blood, urine and other fluid and tissue tests from a network provider. Your chosen GP must ask for these tests by filling in a KeyCare pathology form.

Out-of-hospital pathology expenses are not covered on the KeyCare Core plan.

 
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