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Claims Procedure

  • The Scheme strives to make the claims procedure for Members as user-friendly as possible.
  • In most cases, claims are submitted by service providers, i.e. Doctors, Dentists, Physiotherapists,
    and Pharmacists etc., on behalf of the Beneficiaries involved.
  • The Scheme must emphasise, however, that Members should check all claim entries on every
    claims statement to ensure that the services charged were indeed rendered to them:
    • By doing this, Members will be able to notice any inaccurate claims against their benefits.
    • If there appears to be a problem on any claims statement, the Member must first contact the service provider involved and enquire about the claim(s) submitted.
    • If services were indeed not rendered, contact the Scheme and point out the discrepancies, as the Scheme would like to ensure that the Member only pays for services rendered.

Claims for cash payments

  • If Members pay cash for services covered by their benefits, they can claim back directly from the Scheme:
    • When paying cash, please remember to request a detailed account and a receipt as proof of payment.
    • Clearly mark the account submitted as ‘Refund Member’.
  • Before submitting these claims, ensure that all accounts show the following details:
    • Member information:
      • The Principal Member’s initials and surname as it appear on the latest membership card;
      • The membership number;
      • The name of the Scheme and the benefit option;
      • The patient’s first name(s) and surname, and dependant code as indicated on the latest membership card.

Please note: Ensure that the Scheme has the correct banking details for claims reimbursement.

  • Provider information:
    • The name and practice number of the service provider (Doctor, hospital, pharmacy, etc.);
    • The referring Doctor and practice number, in the case of a Specialist’s account.
  • Services rendered:
    • The date of the service or treatment;
    • The nature and cost of each service or treatment item and the tariff code(s) [ICD-10 code(s)] involved;
    • The duration of an operation (where applicable);
    • The name, quantity, price and NAPPI code of each item of medication (where applicable).

Take note: If the claim submitted does not contain all the necessary information, it will delay the process, thus delaying benefit payment.

  • The Principal Member must sign and mail the original account and receipt to:
    KeyHealth Medical Scheme
    P.O. Box 14145
    Lyttelton
    0140
  • Scheme reimbursement to Members:
    • Any money owed to Members will be paid into their bank account, provided that the Scheme has their correct banking details;
    • Payments to Members are made monthly, provided that the amount payable is in excess of R50,00. If the amount payable is less than R50,00, payment will only be made once the accumulated amount reaches R50,00.
  • Submission of claims:
    • Claims received by the Scheme within four (4) months of the date of treatment or service, will
      be processed according to Scheme Rules;
    • If an account is not submitted within the above mentioned period, no benefits will be payable.

Please note: A receipt without the appropriate detailed account will not be considered for payment.

  • Claims information supplied:
    • Processed claims will be indicated on the claims statement as follows:
      • Amounts paid by the Scheme, and to whom payment was made;
      • Refunds to Members by the Scheme (if any);
      • Payments owed to the Scheme by Members or any service provider (Doctor, hospital etc.);
      • The balance of Member benefits for the current benefit year.
    • Members will also receive e-mail confirmation of claims processed (if the Scheme has the e-mail address on its database).

Claims submitted to the Scheme by the service provider:

  • Most providers of medical services and pharmacies have an electronic link to the Scheme, meaning that claims are submitted directly to the Scheme on behalf of Members.
  • Members are entitled to receive copies of these accounts from the service provider(s) involved.

Outstanding claims on resignation or death:

  • Claims submitted within four (4) months will be considered for payment, provided the service date was prior to the date of resignation or death of the Beneficiary involved.

Most common reasons for partial payment of claims:

  • There may be a difference between the actual claim for the services rendered and the benefit paid by the Scheme; in other words, where the claim amount exceeds MST;
  • When annual benefits are exhausted;
  • Where co-payments are applicable.

Non-payment of claims:

  • Services, material or medicine items are excluded from the Scheme’s benefits;
  • Service provider is not registered with an acknowledged professional institution;
  • Allocated benefits for a specific benefit year have been exhausted;
  • Invalid tariff code, diagnostic or NAPPI code(s) reflected on the claim;
  • Member or Dependant not registered on the Scheme;
  • Benefits suspended at the time of treatment/service delivery;
  • No authorisation was obtained for a specific service item;
  • Claims have a service date older than four (4) months.