Our claims process is designed to ensure that members are reimbursed quickly and accurately for healthcare services received. Whether settling accounts with a healthcare provider or submitting claims for reimbursement, we are here to guide you every step of the way, ensuring your claims are processed efficiently.
Our Claims Process
When a claim is submitted, it undergoes a thorough review process. This ensures that all necessary documentation is complete and that the claim aligns with a member’s plan and benefits. Depending on various factors, claims can be approved, partially paid, or rejected.
Partial Payments
Partial payments occur when only part of the claim is covered. This could happen if certain treatments or services are beyond the benefit limit or beyond what was authorised by the Scheme, or if additional procedures were undertaken that fall outside your plan’s scope. In such cases, Sizwe Hosmed pays a portion of the claim, and the remaining amount will need to be settled by the member.
Claims Rejection
When a claim is rejected, it means that none of the submitted claim is paid. This can occur for several reasons:
- The required documentation was incomplete or inaccurate.
- The claim was filed after the submission deadline.
- The service provider was not part of the approved network.
- The Scheme did not authorise specialist costs or tariffs.
- The Scheme does not cover the treatment or procedure.
- The treatment was not pre-authorised.
- The benefits were exceeded.
- Duplicate claim.
- Benefits are finished.
How to Avoid Rejections
Always review your plan details to confirm benefits before treatments or procedures to ensure smooth processing. Gather and submit the required documents promptly and consult with your service provider to ensure they are on the Scheme’s approved network and their fees are within the Scheme’s tariffs.
How do I avoid partial payment of my claim or a claim rejection?
- Always review your plan details to confirm benefits before treatments or procedures to ensure smooth processing.
- Gather and submit the required documents promptly.
- Consult with your service provider to ensure they are on the Scheme’s approved network and their fees are within the Scheme’s tariffs.
- Submit your claim within four months (120 days) of the treatment.
- Get a referral before visiting a specialist.
- Ensure your treatment is pre-authorised.
- Ensure that additional treatments suggested by your doctor fall within what was pre-authorised by the Scheme.
Information required when submitting a claim
When you submit your claim, ensure that it has the following information:
Healthcare provider’s name and practice number.
- Principal (main) member’s name and initials.
- Principal member’s medical aid number.
- Treatment date.
- Patient’s name (as per membership card). If the patient is not the main member, please list their date of birth and ID number.
- Amount charged.
- Tariff code (filled in by a doctor or specialist).
- Diagnosis made by the doctor or specialist (ICD10 code).
