Claims Procedure
Claiming from the Scheme is as easy as ABC. Ensure that your claim is submitted for payment within three (3) months from the date of service.
What does a complete claim need?
A copy of the invoice (contents of invoice detailed below) and a receipt (for members seeking reimbursement).
What should the claim invoice have to be valid?
- the surname and name of the member as written on the membership card.
- Member signature to confirm service rendered
- The name of the patient as indicated on the membership card.
- the name of the benefit option.
- the membership number of the member.
- the practice code, name and signature of the health professional or the service provider rendering the service, where applicable.
- the date on which the service was rendered.
- the nature of the service and international classification of disease (ICD) and/ or current procedural terminology (CPT) code or diagnosis code from time to time (Itemised list of all services and their respective individual charges. In the case of a medical practitioner or dentist, a diagnosis of the complaint for which the service was provided, as well as tariff codes for the respective services where applicable)
- Members should submit invoices written in English Language if not so an official and certified interpretation for that particular invoice should be provided.
- the code number of the item of the recognised tariff, where applicable
Referral Claim
All invoices for pathology/laboratory services, speech therapy, physiotherapy, dietetics, occupational therapy, psychology, or any other paramedic/allied/associated health services should be accompanied by a copy of the letter of referral from a medical practitioner or dentist.
Pharmacy Claims
Invoices for medication dispensed by a pharmacy should be accompanied by a copy of the prescription certified by the pharmacist, as a true and exact photocopy of such prescription.
Dental Claims
- the tariff code in accordance with the scale of benefits for the treatment.
- Treatment Plan indicating the following:
- the total cost to be charged for the treatment by the orthodontist.
- the duration of the treatment.
- the initial primary amount payable by the member.
- the monthly amount that the member shall pay.
How is member refund/reimbursement done?
Refunds to members are done electronically; therefore we require the following information:
- Account type (savings, current or cheque)
- Branch code
- Branch number
- Bank name
- Account number
- Account name
- All invoices should be signed by the member or dependent to acknowledge receipt of services being claimed for.
How long does it take to pay claims?
- Upon receipt, processing turnaround is 14 days, at which point, a claims run is done weekly
- For member reimbursement, upon processing completion, you will get an SMS notification about the impending payment, and in the following days, payment will reflect into your account.
How do I send Claims?
- Ensure the details are correct and itemised accordingly.
- We accept both hand delivered and posted original invoices.
*As a precaution members are encouraged to make copies of all their submissions.
