PMB Explained

What Prescribed Minimum Benefits actually are — and how to use them.

What is a PMB?

A Prescribed Minimum Benefit is a set of conditions and treatments that every registered South African medical scheme must cover — regardless of your plan, your savings balance, or what your benefit guide says. PMBs are defined by law under the Medical Schemes Act 131 of 1998 and cover approximately 270 medical conditions, including amputation.

What this means for amputees

  • If your amputation is linked to a PMB condition — trauma, diabetes, vascular disease, or cancer — your scheme must cover your prosthetic care at the prescribed level of care
  • Your scheme cannot apply a rand limit or co-payment to a PMB, provided you follow the correct protocols
  • The relevant PMB condition codes for amputees are: 901H (traumatic amputation), 915E (diabetic complications) and vascular/oncological codes
  • PMBs are paid from risk funds, not your savings or day-to-day benefits — your scheme cannot argue that your benefit has run out
  • Your prosthetist can assist with the documentation and motivation required

The one catch

The phrase "subject to protocols" is where most claims go wrong. Your scheme has the right to prescribe how your PMB is treated — which means they can require you to use specific providers, follow pre-authorisation processes, and provide clinical motivation. If you bypass these protocols, the PMB protection can fall away. Always get pre-authorisation before any prosthetic fitting.

How to Claim Your PMB — Step by Step

1

Confirm your amputation qualifies as a PMB condition

Speak to your surgeon or GP. Ask them to confirm the ICD-10 code for your amputation and whether it links to a PMB condition. Common codes: traumatic (S48, S58, S68, S78, S88, S98), diabetic vascular (E11), peripheral vascular disease (I70–I79).

2

Contact your medical scheme's PMB department

Phone your scheme and specifically ask for the PMB team or chronic/managed care division. Say: "I need to apply for PMB cover for a prosthetic limb following amputation." Request the PMB application forms.

3

Complete the PMB application forms

Three parties must provide input: You (member section), your doctor or surgeon (clinical motivation — diagnosis, treatment necessity, prognosis), and your prosthetist (device specification, quotation, NAPPI codes for all components).

4

Submit and track your application

Submit everything together — incomplete applications cause delays. Note your reference number. Your scheme is legally required to respond within 60 days. Follow up at 30 days if you have not heard back.

5

Obtain pre-authorisation before your fitting

Once approved, your scheme will issue a pre-authorisation number. This must be in place before your prosthetist begins fabrication. No exceptions. Without it, your claim can be rejected.

6

Proceed with fitting and claim

Your prosthetist submits the claim to your scheme using your pre-auth number, the NAPPI codes for all prosthetic components (socket, liner, foot/knee, adapters), and the ICD-10 diagnosis code. Keep copies of everything.

7

Appeal if you are refused

If your PMB claim is denied, you can appeal — first to your scheme's internal appeals process, then to the Council for Medical Schemes (CMS): 0861 123 267 or complaints@medicalschemes.co.za. A valid PMB refusal is rare. Most denials are procedural and reversible.