Medihelp and rehab: understanding the PMB route

Medihelp’s 2026 rules are clear: substance-abuse treatment is excluded unless the PMB regulations require it. That sounds discouraging, but it doesn’t mean “no cover”. It means the PMB route is the way in, and the paperwork matters. Here’s how it works.

If someone is in danger right now (a seizure, severe confusion, hallucinations, chest pain, or they can’t be woken), don’t wait for an authorisation. Call an ambulance on 10177 (or 112 from a cell phone) or go to the nearest emergency unit. Schemes treat genuine emergencies differently from planned admissions.

Liberty Home bills Medihelp directly. We obtain the pre-authorisation from Medihelp, send the account to Medihelp ourselves, and Medihelp pays us directly at a fixed rate for the authorised days. A co-payment applies; we’ll explain it before admission. Detox isn’t covered: South African medical aids don’t currently pay for detox at Liberty Home, including the 3-day detox benefit, so it is self-funded.

In short: Medihelp excludes treatment of alcoholism and drug abuse, and services by institutions registered under the Prevention of and Treatment for Substance Abuse Act, except where the Medical Schemes Act regulations require cover. In practice, cover is through the PMB route, subject to registration, authorisation and protocols.

Call admissions +27 60 014 4200

WhatsApp +27 84 775 8623

What Medihelp publishes (2026)

The exclusion. Medihelp’s 2026 exclusions list excludes “treatment of alcoholism and drug abuse as well as services rendered by institutions which are registered in terms of the Prevention of and Treatment for Substance Abuse Act 70 of 2008 or other institutions whose services are of a similar nature, other than stipulated in the Regulations to the Medical Schemes Act”. The same wording appears in the 2026 exclusions for MedPlus, MedElite, MedSaver, MedMove and MedReach.
The PMB route. Medihelp’s PMB guide says that to get PMB cover the condition must be on the PMB list, the treatment must match the defined PMB treatment, protocols and formularies must be followed, and on some plans you must use Medihelp’s network.
Registering a PMB condition. Download the “Register your PMB condition” form from the Member Zone and email it to preauth@medihelp.co.za. Medihelp then issues an authorisation schedule listing the approved services.
Hospital admissions. For a planned PMB admission you must get pre-authorisation to avoid a co-payment. For an emergency admission, authorisation must be requested on the first workday after admission.

What this means for an admission at Liberty Home

We bill Medihelp directly. Liberty Home is registered with Medihelp for direct payment, so we obtain the PMB authorisation and Medihelp pays us directly at a fixed rate for the authorised days.
Liberty Home Manor is registered under Act 70 of 2008, which is exactly the type of institution Medihelp’s exclusion names, except where the PMB regulations apply. So any Medihelp funding would come through the PMB route, at PMB level of care and on Medihelp’s terms.
Medihelp may require a network or DSP for PMB treatment on your plan. We’ll check this with you before admission.
Anything outside the PMB authorisation, including Phases 2 and 3, should be planned as self-funded.

What the law says every scheme must cover (PMBs)

Every registered medical scheme in South Africa must cover a defined list of Prescribed Minimum Benefits (PMBs) under the Medical Schemes Act 131 of 1998. The Council for Medical Schemes (CMS) lists the substance-use PMBs as:

PMB code (DTP)	Condition	Treatment the scheme must fund
182T	Abuse of or dependence on a psychoactive substance, including alcohol	Hospital-based management up to 3 weeks a year
910T	Alcohol withdrawal delirium; alcohol intoxication delirium	Hospital-based management up to 3 days, leading to rehabilitation
910T	Delirium caused by amphetamines, cocaine or other psychoactive substances	Hospital-based management up to 3 days

Three points from the same CMS guidance matter most for families:

PMBs cover in-patient (“hospital-based”) care. The CMS states that the PMB regulations do not include out-patient treatment for substance abuse.
Schemes may appoint designated service providers (DSPs). If you choose a non-DSP voluntarily, the scheme may ask you to pay part of the bill as a co-payment. The CMS advises getting this clarified in writing, which we will help you do.
To be paid as a PMB, the diagnosis must be on the PMB list, the treatment must be PMB level of care, and the scheme’s rules (pre-authorisation, DSP, protocols) must be followed.

These are the minimums schemes must fund in general, not a promise about any particular clinic. South African medical aids don’t currently cover detox at Liberty Home, including the 3-day detox benefit; detox here is self-funded.

Why 28 days and the scheme’s day limit don’t always match

Our minimum stay is 28 days per phase, because that is roughly how long it takes to stabilise, complete detox and do real therapeutic work. The PMB benefit for substance dependence, by contrast, is defined by the CMS as hospital-based management up to 3 weeks a year. So even when Medihelp authorises a PMB admission, the authorised days may be fewer than a full phase. Phases 2 and 3 are usually a different level of care from what schemes fund as in-patient treatment.

We would rather you know this on day one than discover it at discharge. We’ll show you the gap, if there is one, before you commit to anything. You can see our indicative self-funded prices on rehab costs in South Africa.

Step by step: from first call to admission

Call or WhatsApp us. Phone +27 60 014 4200 or WhatsApp +27 84 775 8623. We’ll listen, ask a few safety questions about withdrawal risk and explain the options.
Clinical screen. A member of the clinical team assesses the person, often on the same day. The assessment produces the diagnosis, ICD-10 code and treatment plan the scheme will ask for.
Pre-authorisation: we obtain it. Liberty Home requests the pre-authorisation from Medihelp, with the diagnosis and clinical motivation signed by our doctor or psychiatrist. The family doesn’t have to do this. Medihelp needs the PMB condition registered and the admission pre-authorised, with supporting clinical information (Medihelp PMB guide). We handle both with the patient’s consent.
The scheme’s decision. Medihelp decides whether the admission is authorised and for how many days, and issues the authorisation number. We’ll go through the decision with you.
Billing and the co-payment. We bill Medihelp directly, and Medihelp pays a fixed rate for the authorised days. A co-payment applies; we’ll explain it before admission. At the same time we explain anything else that is self-funded (for example detox, which South African medical aids don’t currently cover at Liberty Home, days beyond the authorisation, or Phase 2 and 3) and any deposit.
Extensions. If the clinical team believes a longer stay is needed, we can apply to Medihelp for an extension. Each extension needs a new pre-authorisation, and Medihelp decides. Progress reports go to Medihelp only with the patient’s consent.

What the family needs to have ready

We obtain the pre-authorisation from Medihelp, and it goes much faster when we have the following:

The patient’s membership card: membership number, dependant code and option/plan name
ID number (or passport number) for the patient and the main member
Details of the patient’s GP and of any psychiatrist or psychologist they already see
A list of current medication, including anything bought over the counter
Previous admissions, detoxes or hospital stays, with approximate dates
A short, honest account of what is being used, how much and for how long. Our clinicians use this for the medical assessment, and it is treated confidentially.
A contact person for the family and a way to pay the co-payment, the detox and any days the scheme doesn’t authorise

Consent matters. Our patients are adults, so we need the patient’s own consent before we share their health information with their scheme (including progress reports) or with family members. If your loved one isn’t ready to talk to us yet, call us anyway. We can guide you on how to have that conversation (see how to help someone with an alcohol problem).

ICD-10 codes: what they are and who chooses them

Medical schemes pay claims against a diagnosis code from the ICD-10 system. Substance-use conditions sit in the block F10–F19, “Mental and behavioural disorders due to psychoactive substance use”. For example, F10 covers alcohol and F11 covers opioids, and the fourth character shows the type of problem (“.2” is dependence syndrome, “.3” is withdrawal state).

The diagnosis and code come from a clinician after a proper assessment. Families should never pick a code themselves. The code has to reflect the person’s actual clinical picture, because schemes compare it with the motivation and treatment plan. The diagnosis and the clinical motivation we send to the scheme are signed by our doctor or psychiatrist.

About Liberty Home Manor

Liberty Home Manor is a residential addiction treatment centre for adults (18+) at 5 Boulder Road, Marina Da Gama, Cape Town. Here are the facts a medical scheme case manager, or a worried family, usually asks about first:

Registration. The Manor is registered with the Department of Social Development under the Prevention of and Treatment for Substance Abuse Act 70 of 2008: certificate 15/10/3/4/2-17/2026, for a maximum of 21 adults, valid until 14 July 2031. You can see the certificate on our licensing and clinical governance page.
Detox on site. We detox all substances on site, with registered nurses on duty 24/7 and doctors on call around the clock. If withdrawal becomes medically acute, our doctors refer to hospital and we stay involved until the person can safely return.
Medication and therapy. Registered nurses dispense all medication. Psychological care is led by an HPCSA-registered clinical psychologist, and we treat co-occurring conditions such as depression, anxiety and trauma alongside the addiction (see dual diagnosis treatment).
A phased programme. Phase 1 (primary care) and Phase 2 (secondary care) take place at the Manor. Phase 3 (supported, tertiary living) takes place at our Lodge in Kenilworth. Each phase has a minimum stay of 28 days. More on our phases of recovery.
Medical aid. We bill your medical aid directly for the programme. We obtain the pre-authorisation for you, and the scheme pays us directly at a fixed rate for the authorised days. A co-payment applies; we’ll explain it before admission. Detox is not covered: South African medical aids don’t currently pay for detox at Liberty Home, including the 3-day detox benefit, so detox is self-funded, and we’ll give you the cost before admission. Liberty Home Manor’s practice number is 1355821, and we are registered for direct payment with many South African schemes, including Discovery, GEMS, Bestmed, Medihelp and Profmed. Registration with Momentum and the Medscheme-administered schemes (such as Bonitas, Polmed and Fedhealth) is in progress. Under Prescribed Minimum Benefits, medical aids pay for 21 days of inpatient treatment; the balance of the programme is a co-payment. How many days your scheme authorises depends on its rules and your option, and we go through this with you before admission.

Frequently asked questions

Does Medihelp cover rehab?

Medihelp excludes treatment of alcoholism and drug abuse, and services by institutions registered under the Prevention of and Treatment for Substance Abuse Act, except where the Medical Schemes Act regulations require cover. In practice, cover is through the PMB route, subject to registration, authorisation and protocols.

Does Medihelp cover rehab at Liberty Home?

Yes, we bill Medihelp directly. Liberty Home is registered with Medihelp for direct payment, so we obtain the pre-authorisation and send the account for the authorised days to Medihelp ourselves. Because Liberty is registered under Act 70 of 2008, Medihelp funding, if any, comes through the PMB route only. We check your option and the authorisation with you. A co-payment applies; we’ll explain it before admission. Detox isn’t covered: South African medical aids don’t currently pay for detox at Liberty Home, including the 3-day detox benefit, so it is self-funded.

Who registers the PMB condition with Medihelp?

We arrange the PMB registration and pre-authorisation with the patient’s consent. Medihelp’s process uses its ‘Register your PMB condition’ form, may ask for medical reports, and ends with an authorisation schedule listing approved services.

What if the admission was an emergency?

Medihelp’s PMB guide says authorisation for an emergency admission must be requested on the first workday after the admission.

Will Medihelp pay for Phase 2 or Phase 3?

Phase 2 (secondary care at the Manor) and Phase 3 (supported living at our Lodge in Kenilworth) are a different level of care from the in-patient treatment schemes fund under PMBs. Assume they are self-funded unless your scheme confirms otherwise.

Which ICD-10 code is used for a Medihelp rehab authorisation?

Substance-use conditions are coded in the ICD-10 block F10–F19 (for example F10.2, alcohol dependence syndrome). The code is chosen by the assessing clinician from the actual clinical picture, never by the family, and it has to match the motivation sent to the scheme.

What if Medihelp declines the authorisation?

We ask the scheme for the reason in writing. Often it comes down to missing clinical information, a DSP requirement or the level of care, and a fuller motivation can change the outcome. If you believe a PMB has been wrongly refused, you can use the scheme’s internal dispute process and then lodge a complaint with the Council for Medical Schemes. Self-funding is also an option, and we’ll explain the costs so you can compare.

Talk to us before you decide

You don’t need to understand your Medihelp benefits before you call. That’s our job. Phone admissions on +27 60 014 4200 or WhatsApp +27 84 775 8623. We’ll talk you through the next safe step and deal with your scheme for you. You can also use our contact form.