Claims Procedure

• 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 appears on the latest membership card
  • The membership numbers
  • 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.

• 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

• 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)
• 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

• Any money owed to a member 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 more than R50. If the amount payable is less than R50, payment will only be made once the accumulated amount reaches R50

• According to Scheme rules, only claims received by the Scheme within 4 months of the date of treatment or service will be processed.
• If an account is not submitted within 4 months of the date of treatment or service, no benefits will be paid.
• A receipt without the appropriate detailed account will not be paid.

• 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)

• 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

• 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.

• There may be a difference between the actual claim for the services rendered and the benefit paid by the Scheme. This happens when the claim amount exceeds MST
• When annual benefits are exhausted
• Where co-payments are applicable

• 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 depleted
• 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