PMB compliance review for medical scheme policy. Before the Registrar - or a complaint - finds the gap.
Avidara reads your scheme's clinical and funding policy, protocol, formulary, rule amendment, SOP, or treatment algorithm against what the Medical Schemes Act and its Regulations actually require - and returns severity-rated findings with the specific regulation cited.
Minutes.
Report in your inbox, fast
50+
Regulatory frameworks encoded, platform-wide
100%
Your control preserved
Zero gaps
Consistent every review
Active Reviews
AVD-00042
Review in progress · In Review
AVD-00039
Previous review · Complete
AVD-00031
Queued document · Pending
Compliance Review - AVD-00042
Managed Healthcare · Medical Schemes · Document analysis complete
Findings
Critical non-conformance identified. Requires correction before approval.
Major deviation from regulatory requirement. Action required.
Incomplete supporting documentation. Cross-reference missing.
Minor formatting non-conformance. Advisory.
Who this is for
Avidara serves 18 regulated industries, each with its own ruleset - and this one speaks a different language than most. If you think in PMB, DTPs, CDL, and CMS Circulars - not SAHPRA submissions - this is built for you.
Scheme compliance & clinical governance teams
The person who signs off on a funding policy, a rule amendment, or a clinical protocol before it goes live.
Managed-care administrators & consultancies
Firms that review scheme policies, develop SOPs, and build treatment algorithms against PMB requirements on a scheme's behalf.
The challenge
Clause-level drift survives internal review.
Prescribed Minimum Benefits aren't optional and they aren't negotiable - but a scheme's own policy wording is where PMB entitlement most often quietly narrows. A co-payment clause that shouldn't apply at a DSP. A sub-limit on a benefit that's meant to be funded in full. A non-formulary exception that's missing entirely.
These aren't dramatic refusals - they're the kind of clause-level drift that survives internal review because nobody reads the whole policy against the regulation line by line. It's exactly the kind of finding the Council for Medical Schemes catches on complaint.
Unlawful sub-limit on a fully-funded PMB benefit
A scheme's funding policy imposed an R500,000 annual sub-limit on PMB oncology treatment - a benefit Regulation 8 requires funded in full, without a sub-limit.
Non-DSP co-payment exception incomplete
A co-payment applied when a member used a non-Designated Service Provider, but the exception wording omitted the required 'no DSP reasonably accessible' ground.
Pre-authorisation clause could downgrade an emergency claim
A 24-hour pre-authorisation requirement, applied without an emergency carve-out, would have downgraded a genuine emergency PMB claim.
What is Avidara
Not a consultancy. A compliance intelligence layer.
Avidara encodes the regulatory rulebook for your industry and applies it consistently, exhaustively, and independently every review. The methodology is universal. Only the ruleset changes per industry.
"The market invested in compliance infrastructure. Avidara addresses compliance intelligence. That is the gap."
The findings are ours. The decisions are yours.
01
Speed beyond human capacity
Every PI reference cross-checked, every claim validated, every mandatory element verified - in parallel, not sequentially.
02
Exhaustive consistency
No reviewer fatigue. No commercial pressure. The same rigour from finding one to finding fifty - every single time.
03
Independence preserved
Avidara flags, analyses, and reports. Your team reviews, validates, and owns every decision. Control stays with you - always.
Five services
One methodology, five ways it applies.
All five run on the same review engine, model, and quality rubric as every other Avidara service - the same standard every vertical on the platform ships at.
PMB Policy Compliance
A scheme's clinical or funding policy against PMB scope - the 271 DTPs, 27-condition CDL, no co-payment or sub-limit at a DSP, correct non-DSP exception wording.
Protocol / Formulary Review
A clinical protocol or drug formulary against Regulation 15H/15I - specifically whether the mandatory 15I(c) exception (fund a non-formulary alternative when the formulary drug isn't clinically appropriate) is present and correctly scoped.
Rule Amendment Readiness
A proposed rule amendment against the legal test the Registrar applies under section 31(3) - fairness to members, consistency with the Act - before it's submitted.
Clinical / Funding SOP
A scheme's internal SOP against its own registered policy, checking the SOP doesn't contradict the policy on a PMB-relevant point.
Treatment Algorithm Alignment
A clinical pathway against DTP-specified treatment - flags any branch that would de-prioritise or deny a PMB-eligible member funded care.
All five optionally take a second reference document - your DSP provider directory, current scheme rules, or existing policy - never required, always used when supplied, never guessed at when it isn't.
How it works
Three steps. Zero ambiguity.
You bring the document. Avidara brings the rulebook. You get a clear, structured finding report before anything leaves your desk.
New Review
Drop your document here
PDF, DOCX, XLSX, PPTX, JPG, PNG - max 50 MB
MedScheme_FundingPolicy_PMB_Review.pdf
2.1 MB · Medical Schemes Act · Regulation 8/15H/15I · Ready
Real result, not a demo
This exact review ran against production - not a demo environment.
On 26 August 2026, the day this vertical shipped, Avidara ran a real end-to-end PMB Policy Compliance review against a test document modelled on a realistic scheme funding policy, with deliberately planted PMB violations - including the three findings shown above.
The review caught every planted issue - and surfaced one issue that hadn't been deliberately planted. Evidence the model is reasoning about the actual policy text, not pattern-matching a fixed list.
What this is - and isn't
A supporting tool. Not a replacement for your clinical governance.
- It's a supporting tool, not a replacement for the scheme's own clinical governance or the Registrar's approval authority.
- It does not adjudicate an individual member's claim or complaint.
- It does not assess the scheme's financial soundness or solvency - that's a different regulatory question entirely (Section 35), out of scope.
- Every finding cites the specific regulation - Regulation 8, 15H, 15I(c), section 31(3) - so a human reviewer can verify it, not just trust it.
Why Avidara
Built differently, by design.
No internal bias
Avidara answers only to the regulatory rulebook, not to commercial timelines, marketing budgets, or launch pressure.
Intelligence, not checklists
Findings come with context - the exact PI section, why it matters, and what correction is required. Not a flag, a path forward.
Control stays with your team
Avidara produces findings. Your team reviews, validates, and owns every decision. We are a prerequisite to your compliance decision, never a substitute.
Universal methodology, vertical rulesets
The same analytical framework whether the document is a pharma PI, a transport permit, or a chemical SDS. Only the encoded ruleset changes.
Consistent at scale
No reviewer fatigue, no variation between team members. The same rigour from review one to review one thousand.
Structured for your compliance record
Every report formatted for direct inclusion in your compliance record - with version control, outcome status, and sign-off blocks.
Documents stay in our environment - by design
All AI processing runs within Avidara's private cloud infrastructure. Your documents are never transmitted outside that environment and never used to train any model - by contractual terms and by architecture. The uploaded file itself is automatically and permanently deleted 90 days after upload, never indefinite - your findings and report stay available in your review history for the life of your account.
Systematically monitored, not static.
Avidara monitors regulatory sources relevant to your industry daily, and new sources are added as your account is onboarded. Detected changes are reviewed and incorporated into the applicable checklist - not applied automatically, but never left unaddressed.
Not in Managed Healthcare?
Avidara serves multiple regulated industries with the same analytical rigour - only the ruleset changes.
Book a review
Ready to close your compliance gaps?
Two ways to engage - pick the one that fits your situation, or tell us what you need and we will recommend the right approach.
No commitment required. We will confirm scope and turnaround before any work begins.