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.

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