Why won’t my
medical aid pay?
We are often criticised by members on social media for
claims that weren’t paid. There are, however, two sides
to every story and the problem doesn’t always lie with
the medical scheme. There are a variety of reasons for
non-payment, ranging from members not following the
correct claiming procedures or rules, to benefits being
depleted or even providers not billing correctly.
In the following article we’d like to share some tips on
what might have gone wrong and how to fix it.
Your membership number
This may sound simple but it is surprising how often
an incorrect membership number or dependant code
is submitted with a claim. In some instances, this
information is omitted or incomplete. A medical scheme
cannot pay without proof that you had the treatment.
Remember to update your details if you have changed
your medical aid option or medical scheme.
ICD-10 codes
ICD-10 codes are used by medical schemes and healthcare
providers, including doctors and specialists, to identify
specific conditions. These must be correct as they are
a diagnosis for specific conditions. If there is no ICD-10
code or, for some reason that condition is not covered by
your medical aid, the account won’t be paid.
Schemes also have sub-limits, for example they agree to
pay for rehabilitation and the amount they will cover is
finite, so check prior to the treatment. Certain dental
procedures have definite sub-limits so it is important
to read the fine print and check your policy for what is
covered and what is not.
Your contributions are not up-to-date
It sounds simple but check that your debit order has
gone through or that your employer has paid your
contribution, as non-payment of premiums could result
in your bill not being paid, especially if your membership
is suspended.
The claim has expired
Be aware that there is a cut-off date for submitting
a claim. It is usually four months from the date of
treatment. Ensure that the correct date is on the top of
the account.
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Your benefits are depleted
If you do not manage your medical aid benefits carefully
you can run out of benefits before the end of the year.
This means that you may have to pay the bill yourself.
Different options have different limits for various
procedures so, once again, make sure you understand
what your option covers. Medical schemes are required
to pay for Prescribed Minimum Benefits (PMBs) in full,
but you may have to use a specific provider.
Waiting periods may apply
When you join a new scheme there is a waiting period
of three months and sometimes, based on your medical
history, a twelve month exclusion could be enforced for
certain conditions. If you claim before the waiting period
is up, the bill will not be paid.
Your hospital/doctor is not on the network
Most schemes have hospital and doctor networks who
agree on certain rates for their members. If you choose
to go to another hospital or a private doctor you could
end up paying a large portion of the bill.
You didn’t use a Designated Service Provider
A Designated Service Provider (DSP) is a specific provider
that has been appointed by a medical scheme for a
specific service. If you choose not to use a Designated
Service Provider, you may have to pay a co-payment or
not be covered – depending on the Scheme Rules or your
specific plan limits.
Pre-authorisation was not obtained
If you are going to undergo a procedure you need to get
authorisation from your medical aid ahead of going to
hospital and, once again, make sure you have the right
information and ICD-10 codes for this.
You’re using medicine that’s not on the
formulary
Every scheme has a formulary, which lists chronic
medication approved by your medical aid. These are often
generics which are copies of the original medication but
more affordable. Ask your pharmacist for a generic as it
will ensure your benefits last longer.
The procedure or treatment may be an
exclusion
All medical schemes have a list of exclusions which are
not covered. This often includes cosmetic surgeries and
non-medical expenses.
If you read the small print and know exactly what the
rules are for your medical aid and the plan you are on,
you will be able to ensure that your benefits last as long
as possible and that the bills are paid.