Letters
PMB application and motivation letter template
By Naledi Mokoena · 7 min read · Updated 24 June 2026
To get a condition covered as a prescribed minimum benefit (PMB), send your scheme a PMB application with a motivation from your treating doctor that includes the diagnosis, the ICD-10 code, and the treatment plan. By law your scheme must pay in full for the diagnosis, treatment and care of conditions on the PMB list, usually through a designated service provider (DSP).
Use the template below, signed or supported by your doctor. PMBs cover a defined list of about 270 conditions plus 27 chronic conditions on the Chronic Disease List (CDL).
If the scheme still refuses, you can dispute it and escalate to the CMS.
What a PMB is
Prescribed minimum benefits are a set of conditions that every registered medical scheme must cover in full, no matter which plan you are on. They include a list of about 270 conditions and medical emergencies, plus 27 chronic conditions on the Chronic Disease List such as asthma, diabetes and hypertension.
The scheme can require you to use a designated service provider (DSP) and to follow approved treatment protocols. If you do, the scheme must pay the cost in full without using your savings or day-to-day benefits.
PMB application and motivation template
Ask your doctor to complete or sign the clinical part. Replace every [PLACEHOLDER].
[Your full name]
[Membership number]
[Email] | [Cellphone]
[Date]
The PMB / Clinical Department
[Scheme name]
RE: Application for PMB cover - member [MEMBERSHIP NUMBER]
Dear Sir or Madam,
I am applying for my condition to be funded as a prescribed minimum benefit.
Patient: [PATIENT NAME AND DEPENDANT CODE]
Diagnosis: [CONDITION]
ICD-10 code: [ICD-10 CODE]
Date of diagnosis: [DATE]
Treating provider: [DOCTOR NAME AND PRACTICE NUMBER]
Motivation from the treating doctor:
[DOCTOR TO DESCRIBE THE DIAGNOSIS, SEVERITY, AND WHY THE PROPOSED TREATMENT IS CLINICALLY APPROPRIATE].
Proposed treatment plan: [MEDICATION / PROCEDURE / THERAPY, with codes].
Proposed provider / DSP: [NAME OF DSP OR REQUEST FOR THE SCHEME'S DSP].
As this condition appears on the PMB list, I request that it be funded in full in line with the Medical Schemes Act, not from my savings or [day-to-day benefits](/guides/day-to-day-benefits/).
Please confirm approval, the approved provider, and any protocol I must follow.
Yours faithfully,
[Your full name]
[ID number]
Doctor's confirmation: [DOCTOR NAME, SIGNATURE, PRACTICE NUMBER]
Get the ICD-10 code right
The single most important detail is the ICD-10 diagnosis code from your doctor. Schemes decide PMB status largely on that code. If a claim was rejected, check that the code on the claim matches your actual PMB diagnosis. A wrong or missing code is the most common reason a genuine PMB claim is refused.
Use the DSP to avoid co-payments
Schemes are allowed to name a designated service provider for PMB conditions. If you use the DSP, the scheme pays in full. If you choose a non-DSP provider voluntarily, the scheme may apply a co-payment. Ask your scheme who the DSP is for your condition before you start treatment, unless it is an emergency.
If the scheme refuses
If the scheme rejects a PMB application or claim, ask for the reason in writing. Then lodge a written dispute with the scheme, and if needed escalate to the Council for Medical Schemes. PMB disputes are common and the CMS regularly directs schemes to pay where the condition clearly qualifies. Our appeal and complaint templates cover the next steps.
Frequently asked questions
What are prescribed minimum benefits (PMBs)?
PMBs are conditions every South African medical scheme must cover in full, regardless of your plan. They include about 270 conditions and emergencies, plus 27 chronic conditions on the Chronic Disease List. The scheme can require you to use its designated service provider.
Does my plan matter for PMB cover?
No. Even an entry-level hospital plan must fund PMB conditions in full. The scheme cannot pay PMB costs from your medical savings account or refuse them because your plan is basic, as long as you follow the protocols and use the DSP.
What is a DSP and why does it matter?
A designated service provider is the hospital, doctor or pharmacy your scheme has contracted for a PMB condition. Use the DSP and the scheme pays in full. Use a non-DSP by choice and you may face a co-payment, except in a genuine emergency.
Why was my PMB claim rejected?
The most common reasons are a wrong or missing ICD-10 code, treatment outside the approved protocol, or using a non-DSP provider. Fix the code or get a doctor's motivation, then resubmit or dispute. The CMS can direct the scheme to pay valid PMB claims.
Can the scheme make me pay a co-payment on a PMB?
Only in limited cases, such as choosing a non-DSP provider voluntarily or not following the approved protocol. For an involuntary use of a non-DSP, for example in an emergency, the scheme must still pay in full.
How long does a PMB application take?
There is no fixed legal turnaround, but most schemes respond within a few weeks. Phone to confirm receipt, get a reference number, and follow up in writing. If the delay is unreasonable, escalate to the CMS.
