Claiming

 

 

How do I submit a claim?

You do not need to complete a claim form – simply submit all invoices directly to the Scheme. Remember to keep a copy for your records.

  1. Before submitting your claim, check that the following information appears on the account:

    • The name of the Scheme
    • Your membership number
    • Surname and initials of member
    • The patient’s first name(s) as it appears on your membership card, together with the date of birth
    • The name and practice number of the service provider (e.g. doctor or pharmacy)
    • ICD10 code
    • A pre-authorisation number on hospital accounts or related accounts
    • Date of service or treatment
    • Amount claimed and tariff code
    • Name, quantity and price for each supply of medicine (where relevant)
    • Duration of operation (where relevant)

    If any of the above information does not appear on the account, it may lead to a delay in the processing of your account. Please request another account from your service provider.

  2. Check that the account details are correct and that you have been charged the correct amount.
  3. If you have already paid the account, clearly write “Account Paid” on the account and attach the receipt.
  4. Keep a copy for your records.
  5. Submit your claim (see below for details).
  6. Your claim will be settled within 30 days of receipt and, in the case of a pre-paid account, the refund will be generated to you.

WHERE TO SUBMIT YOUR CLAIM

Via internal mail:
Nedgroup Medical Aid Scheme
2nd Floor
36 Merriman Avenue
Vereeniging

Via the post office:
Nedgroup Medical Aid Scheme
PO Box 74
Vereeniging
1930

Via fax: 0860 111 784

Via scan: nedgroup.newclaims at medscheme.co.za

 

IF YOU ARE FAXING OR SCANNING CLAIMS

To ensure that claims are promptly processed, please consider the following:

  • Check legibility. (If the scan is illegible, the administrators will be unable to process the claim. If the contact details are not legible, the member can also not be notified of the concerns.)
  • Place your name and contact number on the claim.
  • Use the scan facility, the fax facility or normal postage services (but please do not submit the same claim using various methods, as duplicate claims may also lead to delays).
  • For audits, the administrator is required to retain legible copies of all member claims.
  • Check the size of the email and zip the attachment (if necessary) to ensure that the size of the email is smaller than 2MB. Emails larger than 2MB will not be received by the server.

How can service providers submit claims electronically?

Most service providers submit claims electronically. These claims are then paid directly by the Scheme to the service provider, subject to available limits.

If your service provider uses this facility, ask them for a copy of the claim for your records and check that the services and amounts charged are in fact correct. You do not need to submit a copy, unless you notice on your member statement that the claim has not been processed after a reasonable time. Remember, it remains the member’s responsibility to ensure that claims have been submitted within a period of four months after treatment has been obtained and paid, and you are encouraged to review your monthly claims advice/remittance statements.

If the Scheme amends any of the benefits offered, PLEASE NOTE that claims submitted after these amendments will be paid according to the rules that existed at the date of the service and not the rules that exist at the date when the claims are submitted or received.

HINTS

  • Check whether your doctor has submitted the claim on your behalf.
  • You must submit your claim as soon as possible after receiving the service. If your claim is received later than four months after the date of service, the claim will be considered stale and will not be paid by the Scheme. For example, if you visit the dentist on 20 April, the administrator must receive the claim before 20 August of the same year.
  • Remember to keep all your claims advices, payment advices and personal medical savings account statements for your records.

 

How can I see my claims online?

Members may register on Medscheme’s website and access the following self-help facilities via nmas.medscheme.com, or download and use the new smartphone-friendly Scheme app to see claims, remaining benefits and more.

REGISTRATION INFORMATION

The process to register will only take a few minutes and in future you will have direct access to your medical scheme information.

  1. Go to www.nmas.medscheme.com
  2. Click on LOGIN on the top right-hand corner of the Homepage menu.
  3. Click on Log in as a member.
  4. Click on Register.
  5. Click on the appropriate registration option:
    I would like to register as a Member.
  6. Enter your membership number.
  7. Click on Validate Code once your details have been entered.
  8. Select a beneficiary to register.
  9. Choose a username. Your username has to be longer than 8 characters.
  10. Type in your email address.
  11. Choose a password: Your password must be 8 characters and is case sensitive. No “&” signs allowed.
  12. Click on Create Account.
  13. You will shortly thereafter receive an email from webquery@medscheme.co.za. Click on the Activate link in the email. It will direct you to the login section of the member zone of the site.

You will now be able to login and use the website functionality with your username and password.

Whom should I contact if I have any queries about claims?

Queries
If you have any queries regarding claims, you should contact Medscheme on 0860 100 080

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