Frequently Asked Questions

There are a number of reasons why a Medical Scheme may not pay your claim, under pay it leaving you with a balance to settle, or pay it from the wrong benefit (for example pay it from your Savings when it should have come from another benefit).

The reasons include, in no particular order:

• Incorrect coding by the doctor’s (or other medical provider’s) rooms

• Incorrect processing by the Medical Scheme

• Scheme rules or benefit structures that prevent the payment from being made.

When your condition is a Prescribed Minimum Benefit (PMB) then, subject to some limitations, the Medical Scheme should be paying your medical bills in full, and they should not be paying it out of your savings account.

Diagnosis codes from the International Classification of Diseases, 10th Revision (ICD10) are used to identify a medical condition as a potential Prescribed Minimum Benefit (PMB).

• If you have medical aid cover, then – with some stipulations – your scheme is required to pay for the diagnosis and treatment of the condition in full.

• This payment must not be made from your savings account. Therefore it is important to check where the payment is coming from within your scheme benefits. 

• The most important thing you need to do to access your PMB benefits, is to call your scheme and find out if they use Designated Service Providers (DSPs) and what you need to do to ensure that your claims (for this condition) are correctly paid.

The 270 diagnoses are linked to treatments, and together, these are known as diagnosis treatment pairs (or DTPs).

THE PMBS ARE MADE UP OF:

• Any emergency medical condition
• 270 diagnoses (based on a diagnosis code)
• 25 chronic conditions
(also based on a diagnosis code)

THE STIPULATIONS ARE IMPORTANT:
If there is any dispute about what type of treatment the scheme has to pay for, government treatment standards apply. You have to use Designated Service Providers (DSPs) within reasonable distance from your home or work if you want the account to be paid in full by the medical scheme. However, in an emergency, you need not use a DSP.

PRESCRIBED MINIMUM BENEFITS

Diagnosis codes from the International Classification of Diseases, 10th Revision (ICD10) are used to identify a medical condition as a Prescribed Minimum Benefit (PMB). When a condition is defined as a PMB it means that, if you have medical scheme cover, then, with some provisos, your scheme is required to pay for the diagnosis and treatment of the condition in full. This payment must not be made from your savings account, so check where the payment is coming from within your scheme benefits.

The most important thing you need to do to access PMB benefits is to call your scheme and find out if they use Designated Service Providers (DSPs) and what you need to do to ensure that your claims for this condition are correctly paid.

The PMBs are made up of:

Any emergency medical condition
270 diagnoses (based on a diagnosis code) and,
25 chronic conditions (also based on a diagnosis code)
The 270 diagnoses are linked to treatments and these, together, are known as diagnosis treatment pairs (or DTPs).

The provisos are important.

Firstly, if there is any dispute about what type of treatment the medical scheme has to pay for, then the treatment standards applied in government clinics and hospitals will be taken as the standard. The medical scheme is not required to pay for anything above this standard.

Secondly the medical scheme may contract with some providers (doctors, hospitals, etc.) – known as Designated Service Providers (DSPs) – and require that you use these service providers if you want the account to be paid in full by the medical scheme. If you use a provider that is not a DSP you will have to make some or all of the payment yourself. The DSP must be within a reasonable distance of your work or home and they must be able to provide the services you need. If they are too far from your home, or can’t provide the services you need, then the medical scheme must pay for the services at a non-DSP provider. Also, in an emergency, you need not go to a DSP, and the medical scheme must pay in full.

DECODE MY CLAIM                 HELP ME WITH MY CLAIM

• We ask you to send us more details of the problem – like doctor and hospital invoices, medical aid statements, and so on.
• We evaluate (at no cost to you) your situation based on the documents you send us.
• If, after the evaluation, we believe that we cannot help you, we get back to you and explain why we cannot help and there remains no charge to you.
• If we believe that we can help, we get back to you and explain what we will do – we will need you to sign a consent form so that we can interact with your medical aid and doctor on your behalf.
• If we take the case forward our fee is R575 (inclusive of VAT) OR we can provide the service at no cost if you appoint one of our partner intermediaries as the intermediary of record for your medical aid. This does not cost you anything but does mean that the intermediary will be paid a commission by the medical aid thereafter.