How to Claim Back From Your Medical Aid

Being a member of a medical aid does not guarantee that all your medical bills will be paid directly by your scheme. Certain medical aid restrictions and providers contracted out of medical means that you have to pay cash for these services. In most instances, your medical aid will then reimburse you directly for these costs.

If you have paid cash for any medical service, ensure that you get a statement and a receipt from the provider. While the receipt verifies that cash was exchanged for the service or product, the provider’s statement will contain all the necessary details for your medical aid to process the claim. In this instance, you medical aid will then pay you directly – either by check or via EFT into your bank account.

The following details are necessary for your medical aid to process your claim.

  1. Your provider’s practice number. This is issued to practitioners by the Board of Healthcare Funders and allows your medical aid to identify the individual provider.
  2. Tariff codes. Practitioners are provided with a set of codes for their particular discipline. These codes allows your medical to identify each procedure conducted by your practitioner.
  3. Nappi code. This is the code for registered drugs in South Africa. Your medical aid needs this code to identify which medicine(s) were dispensed or used for your treatment.
  4. Diagnosis. Your doctor has to list the condition for which you were treated. The diagnosis is either written in words or listed as a code, known as the ICD-10 code. These days, most medical aids only require the ICD-10 code.

It is important that your practitioner’s statement or receipt mentions that you paid cash for your services. Errors on the part of the medical aid may mean that your practitioner will be paid directly for the service provided unless the statement clearly states that you paid cash.

Once you have the necessary paperwork, you can either fax, email or post the documents to your medical aid. If your medical aid has an office in your city, you can visit them directly. Your medical aid will process the claim and usually pay you within 30 days.

Additional fees like a levy or co-payment is usually not covered by your medical aid. These fees are payable by the patient and is part of your medical aid’s policy. At times your medical service provider may require an additional payment although they have claimed for the services from your medical aid. This is due to the fact that some procedures are not covered in full by your medical aid plan and you are therefore liable for the remaining amount. This is known as a co-payment.

Sometimes members on a medical aid may have to pay cash for services because of medical aid scheme exclusions for new applicants or certain procedures that are not considered to be a medical necessity. In this case, you cannot claim back any money from your medical aid.

It is also important to note that the fee you paid to your practitioner may not be the amount you are reimbursed by your medical aid. This could occur for a number of reasons like:

  1. Your doctor charged you a higher fee than the NHRPL (National Health Reference Price List). Most medical aids will only pay a fee based on the NHRPL and will not cover any private fees that are higher than the scale of benefits.
  2. Your medical aid does not recognise the specific practitioner, procedure or drug. This could mean that your practitioner is not registered or does not have a valid practice number. Alternatively your medical aid has restrictions on certain drugs and procedures or will only partly pay for it.

It is important to understand these aspects of your medical aid cover. Apart from scheme restrictions and exclusions, it is the practitioner’s right not to deal directly with your medical aid if he/she so wishes. Inefficiency on the part of certain medical aids, exhausted cover and unscrupulous patients have driven many doctors to stop accepting medical aids.

Your doctor may also feel that the fee offered by the medical aid is insufficient for his/her services. If you do not wish to pay cash for any medical service, then you need to speak to your medical aid about their restrictions and exclusions. You will also need to find a provider who will be prepared to deal directly with your medical aid for all the associated costs.