Why Does It Take So Long to Get My CPAP from Medical Aid?

A behind-the-scenes look at the admin jungle of authorising CPAP devices in South Africa

So, your doctor has prescribed a CPAP machine. You’re ready to breathe better, sleep deeper, and stop snoring like a tractor.

But wait… why are we still waiting?

“Didn’t we send everything in?” “Why does it feel like I’m applying for a home loan just to get a breathing machine?” “Why so many forms?!” 😩

Let’s take a light-hearted walk through the CPAP authorisation process with South African medical aids — what’s required, what slows things down, and what you can expect along the way.

🚦 Step 1: The Diagnosis (Can’t Skip This One!)

Before you even think about claiming a CPAP machine, the medical aid needs proof that you actually need one. This starts with:

• A polysomnogram (in-lab sleep study) or home sleep test

• A diagnosis of obstructive sleep apnea (OSA), typically with an AHI (Apnea-Hypopnea Index) ≥15

• In some borderline cases (AHI 5–14), daytime symptoms like excessive sleepiness, hypertension, or heart disease must be documented

✅ Without a clear diagnosis, medical aid will not consider funding your CPAP device.

🧠 A Quick Look at Medical Aid Criteria in South Africa

Most medical aids follow SASSH (South African Society of Sleep Health) guidelines when reviewing claims. Here's what they typically require:

✅ Basic Criteria for Approval:

• AHI ≥15, or

• AHI 5–14 with comorbid conditions (e.g., high blood pressure, heart disease, excessive daytime sleepiness)

• A completed and signed SASSH form from a pulmonologist or sleep specialist

• A detailed sleep study report

• A motivation letter if needed (especially for borderline cases)

• Quotations from an accredited provider

🔍 Some funds (like Discovery and Momentum) are stricter and may require in-lab testing. Others are more flexible if the report is comprehensive.

💬 Each fund has its quirks—some allow rentals, some only approve purchase once in 3 years, and others cap reimbursement at a set limit (e.g., R10,000).

📑 Step 2: The Infamous SASSH Form

This little form causes big delays if not done right.

It must be:

• Fully completed (no blank boxes!)

• Signed by a registered sleep specialist or pulmonologist

• Matched with the attached sleep study report

• Accurate with the prescribed CPAP pressure setting or “auto range”

If anything is missing or signed by the wrong doctor? 💥 Back to square one.

📤 Step 3: Submitting to Medical Aid – Now We Wait…

Once all documents are in order, we submit your application to the medical aid for pre-authorisation.

Required documents include:

• The SASSH form

• Sleep study results

• Quotation

• ICD-10 code: G47.3 (for OSA)

• Motivation letter if needed

From there, it enters clinical review, which can take:

• ⚡️ 2–3 days (if you're lucky), or

• 🐢 7–10 working days (if you're not)

  
  

💸 Step 4: Approval Received – But Hold That Excitement!

When your medical aid approves the device, they issue:

• An authorisation number

• A claimable code (e.g., 271840000 for CPAP therapy)

• Possibly a limit or ceiling amount (e.g., “up to R10,000 approved”)

But here's the important part:

🔐 We do not deliver or issue CPAP machines until full payment has been received.

Even with an authorisation number in hand, most medical aids:

• Only pay after invoicing

• Follow their own monthly or weekly payment cycles

• Take up to 15 working days to pay out

  
  

✅ What are your payment options?

• Option 1: You pay in full upfront, and we assist you in claiming back from the medical aid.

• Option 2: We wait for payment from the medical aid before delivery — this often takes 2–3 weeks after invoicing.

• Option 3: Some patients use gap cover or medical savings to speed things up — ask your provider if that’s an option for you.

Once payment is confirmed:

• We schedule your mask fitting

• Set up your device with the correct pressure

• Give you a proper walkthrough so you know how to use, clean, and sleep like a pro

• 
  

🧾 Step 5: The Final Stretch – Payment Run

Each medical aid has its own rhythm. Here's a rough idea:

Medical Aid	Payment Run Frequency
Discovery	Weekly (usually Wed)
Bonitas	Monthly
GEMS	Monthly
Medihelp	Weekly to bi-weekly
Momentum	Weekly
Polmed	Monthly

⏳ On average, payment reflects 5–15 working days after invoicing — if no additional documents are requested.

🪄 How to Speed Things Up: Pro Tips

✅ Make sure your doctor is a pulmonologist or sleep specialist✅ Get the SASSH form right the first time✅ Let your provider do the chasing — we know who to call and how to speak their language✅ Follow up after 3–5 working days if you hear nothing✅ Ask your fund if you can pre-pay and claim (some reimburse faster this way)

🎯 Final Word

Yes — claiming a CPAP device through South African medical aid is not quite a sprint. It’s a paperwork marathon.

But knowing what’s required (and what can go wrong) helps you avoid the potholes.

Once it’s approved, paid, and set up, you’ll be:

• Sleeping better

• Snoring less

• Feeling sharper

• And protecting your heart and brain with every breath

  
  

So breathe easy — we’re here to help you through the admin jungle one signature at a time. 💙

Need help with your CPAP claim, paperwork, or pressure settings?📞 Contact us at CPAP Equip — we’ll make sure your journey to better sleep doesn’t get stuck in a paper jam.