Medical Aid Tariffs and Codes

Reading through your monthly medical aid remittance can often be confusing with columns of codes that makes little sense to the average person. These tariff codes are a standardised means by which medical aids can communicate with each other, healthcare practitioners and other service providers. It removes the need to describe each consultation, medication or procedure in English or any other language as these codes are universal among all medical aids in South Africa. Although most remittance advices have a description of the service rendered, medication prescribed or procedure conducted, it is important for the medical aid member to understand the relevance of these codes and how it may affect their medical costs.

Types of codes used by medical aids

There are two main types of codes used by medical aids in its billing, payment and administration procedures.

• Medical aid tariff codes are used by all medical aid schemes to indicate the type of treatment or service provided and the associated cost. Each of these codes have the specific and amount attached to it which determines the rate at which any medical service provider will be paid. The pricing for each code is determined by the Department of Health and certain industry players and published in the annual National Health Reference Price List (NHRPL).
•  ICD -10 codes which stands for International Classification of Disease. These codes have been repeatedly revised by the World Health Organisation and is a standardised means to communicate a specific diagnosis or disease. It is used globally and is not specific to medical aid schemes in South Africa. Most schemes, however, uses these ICD-10 codes to indicate the disease for which a medical aid member was treated and subsequently monitor the management of the condition by healthcare providers.

Meaning of tariffs and codes

There are thousands of medical aid tariff codes used by South African medical schemes and healthcare providers. Most of these codes are specific for each healthcare profession meaning that general practitioners would have a set of unique codes, as does a physiotherapist or dentist. Each code has a specific Rand amount attached to it indicating the price which should be paid for the service or procedure. Prescription medication uses a different set of codes known as nappi codes.

The medical aid tariffs are revised annually and determined by the Department of Health with input from medical aid schemes, professional medical associations and other regulatory bodies in the South African healthcare industry. It is then published as the National Health Reference Price List (NHRPL) for the specific year. Medical aids may use this guideline to determine the amount paid for each tariff code. Most medical aids pay according to the NHRPL where they do not pay any more or any less than the amount that has already been set (tariff). This is simply indicated as 100% of NHRPL.

Amount above tariff

Some medical professionals and healthcare providers charge above the tariff stipulated in the National Health Reference Price List (NHRPL). Although individual practitioners are entitled to do so, this does not mean that a medical aid has to pay the amount above and beyond the NHRPL tariff. Any difference has to be settled directly with the healthcare provider by the medical aid member (patient).

Some medical aids have now opted for higher rates for certain medical professions, particularly specialists, and usually only within the hospital environment. This is usually indicated by the medical aid stating that they pay 150% or 300% of NHRPL. It means that a medical aid is prepared to reimburse a healthcare provider by one and a half times (150%) or three times (300%)of the NHRPL tariff. A medical professional can therefore charge the medical aid a higher rate than what is stipulated in the National Health Reference Price List. If the practitioner’s rate exceeds the additional amount which the medical aid is prepared to pay, the patient (medical aid member) is once again liable for the difference.

For example, if the amount for a specific procedure (according to the tariff code) is listed for R100 in the NHRPL, a medical aid will usually only pay this amount to a healthcare professional which means 100% NHRPL. Should the practitioner choose to charge R150, the patient is liable for the R50 difference. Similarly, if the medical aid chose to pay 300% of NHRPL which in this example would be R300, and the medical service provider chooses to bill R400, the patient is then liable to pay the R100 difference.