Claiming Back from your Medical Aid

These days, many doctors and other healthcare providers are contracted out of medical aid. This simply means that the service provider will not accept medical aid payments and you the patient will have to pay for their services from your own pocket. However, as a medical aid member you can recover part of or the entire amount back from your medical aid. The process for claiming back from your medical aid is fairly simple. However, many medical aid members experience difficulties along the line which is more often due to ignorance than ineptitude on behalf of medical scheme workers.

How to claim from a medical aid?

Firstly you will need a statement from your doctor or healthcare service provider. This statement will outline the fees charged and tariff codes for the relevant procedures. Secondly you will need a receipt to prove that you did pay the service provider. Most medical aids now have online claim platforms or you can download and fill out a claim form. These forms and documents must then be faxed to your medical aid. Depending on the documentation and the scheme’s reimbursement process, you can be refunded within 5 to 7 days although many medical aids take up to 14 days to do so.

Problems with Medical Aid Claims

All too often medical aid members experience problems with claiming back from their scheme. These problems are largely due to insufficient documentation and errors on the part of the doctor’s staff.

Tariff Codes

All consultations and procedures have specific tariff codes and amounts as outlined in the National Health Reference Price List (NHRPL). This price list is essentially a guide for medical aids to pay certain amounts for specific tariff codes. Some medical aids may pay slightly higher rates.

If your doctor charges above these rates, the medical aid will only reimburse you at the NHRPL rate. You will have to bear the shortfall. Errors with tariff codes is one of the main reasons for problems with medical aid claims. These codes are usually 5 digits long, although certain practitioners may only use 4 digit code with a zero prefix omitted.

A doctor or service provider from one health care specialty cannot charge for procedures and use the tariff codes of another specialty. There is some degree of overlap with common procedures, however, each practitioner has their own set of codes. While some medical aids will pay 2 to 3 times the NHRPL rate for in-hospital consultations and procedures, most out of hospital rates are paid exactly as per the price list.

Medicines are listed according to NAPPI codes which are much longer and is usually not negotiable in any way. In fact pharmacies cannot charge above these rates. However, some medical aids do not pay for certain medicines and the patient will not be reimbursed or will only be reimbursed for the generic.

Practice Number and Registration Number

Every healthcare professional has two numbers – a registration with their professional council, like the Health Professions Council of South Africa (HPCSA) and a practice number from the Board of Healthcare Funders (BHF). A medical aid claim will never be processed without the practitioners BHF practice number clearly indicated on the statement.

Most healthcare professionals also print their professional registration number on the statement although this is not necessary for medical aid claims. Members submitting claims to their medical aid need to ensure that they enter the practice number, and not the council registration number, on the online forms.

Stamp and Signature

Although a signature is not usually necessary, the statement issued by the doctor should have some means of corroborating its origin. Most doctors will use their professional practice stamp to verify that they issued the statement and some may simply opt to sign on the statement. This is usually necessary as medical aids have faced attempts to members to claim back money with fraudulent statements and receipts.

Payment from the Medical Aid

Most medical aids now only reimburse doctors or patients through an electronic funds transfer (EFT). It is therefore important that your medical aid has your correct bank details in order to complete this payment. Medical aids no longer pay by cheque and never make cash payments. It is therefore important to follow up on this electronic payment and ensure that it reflects on your bank account. Since many medical aids still work on payment runs, either weekly, fortnightly or monthly, sometimes patients may only be reimbursed on these run dates.