How medical-aid claims work in South Africa: a guide for GP practices

Who is involved in a claim

Every claim passes between the same few parties:

• The practice (the provider), identified by its practice number.
• The patient, who is either the main member of the medical scheme or a dependant on the member’s plan, identified by a dependant code.
• The medical scheme, which decides what is covered under the member’s plan.
• The administrator, a company that many schemes use to process claims for them.
• A claims switch, an electronic link that carries claims from practice software to schemes and administrators, and carries responses back.

On the practice side, all of this happens in your billing or practice management software. The quality of the information you capture at the front desk and in the consult decides most of what happens next.

What a claim must contain

The regulations under the Medical Schemes Act set out what an account sent to a scheme must show. In practice, a GP claim needs:

• Practice details: the practice name and practice number, and the treating provider.
• Member details: the member’s name and membership number, the scheme and plan, and the patient’s dependant code.
• The date of service.
• Tariff (procedure) codes for what was done, such as the consultation, with quantities and any modifiers.
• ICD-10 diagnosis codes for why it was done. These have been compulsory on medical-scheme claims in South Africa since 1 July 2005.
• NAPPI codes, quantities and prices for any medicine or consumables dispensed.
• An authorisation number, where the scheme required pre-authorisation.
• The amount charged for each line.

The ICD-10 code matters for more than compliance. Schemes use it to decide which benefit pays, and to recognise conditions that fall under the Prescribed Minimum Benefits (PMBs). A vague or incorrect code can push a claim into the wrong benefit or get it rejected.

The claim, step by step

1. Check the patient’s membership before the visit. Confirm the scheme, plan, membership number and dependant code. Where the scheme offers it, run a benefit check to see whether the patient is active and has funds available.
2. Get any authorisation you need. Some procedures, medicines and scans need pre-authorisation. Record the authorisation number so it goes on the claim.
3. Record and code the visit. Capture the procedures, dispensed medicine and diagnoses. Use the most specific ICD-10 code that fits, and the primary diagnosis first.
4. Create the invoice. Tariff codes, NAPPI codes and ICD-10 codes come together on one invoice per visit.
5. Submit electronically. The claim goes through a switch to the scheme or its administrator. Many schemes respond within seconds or minutes, telling you whether the claim was accepted, partly paid or rejected, and why.
6. Deal with rejections quickly. Fix the reason given, then resubmit. Keep a note of what was changed.
7. Reconcile the remittance. The remittance advice shows what the scheme actually paid. Match it to your invoices, then collect any balance from the patient.

The time limits you need to know

The Medical Schemes Act and its regulations set clear deadlines for both sides:

If a scheme does not tell you within 30 days that a claim is wrong, or doesn’t give you the chance to correct it, the scheme carries the burden of proving the claim was wrong in a dispute. Keep a record of when you submitted each claim and what came back.

Why claims get rejected

Most rejections fall into a handful of groups, and nearly all of them can be caught before the claim is sent:

• Membership problems: wrong membership number or dependant code, a lapsed member, or a patient who has changed plan.
• Coding problems: a missing or invalid ICD-10 code, a code that doesn’t match the procedure, or a missing modifier.
• Benefit problems: the relevant benefit is exhausted, or the service isn’t covered on that plan.
• Missing authorisation for a service that needed one.
• Timing: the claim was submitted after the four-month limit, or is a duplicate of one already processed.

The fix is the same each time: check membership and benefits before the visit, code carefully during it, and read every response the scheme sends back.

Getting paid faster

• Submit on the day. A claim sent the same day is fresh in everyone’s mind if it comes back.
• Work rejections daily. The 60-day resubmission window is generous, but cash flow isn’t.
• Track by age. An age analysis (0–30, 31–60, 61–90 and 90+ days) shows which accounts need attention first.
• Separate “accepted” from “paid”. An approved claim is a promise. Only the remittance shows what was actually paid.
• Know what each claim costs you. Many practices pay a fee per claim through their software or switch. Over a year that adds up. See claim switching fees explained.

Frequently asked questions

How long do I have to submit a medical-aid claim?

Until the last day of the fourth month after the month in which the service was provided, under Regulation 6 of the Medical Schemes Act regulations.

How long does a medical scheme have to pay?

A scheme must pay a valid claim within 30 days of receiving it, in terms of section 59(2) of the Medical Schemes Act.

What happens if a claim is rejected?

The scheme must tell the member and the provider why within 30 days. You then have 60 days from the date it was returned to correct and resubmit it.

Is an ICD-10 code required on every claim?

Yes. ICD-10 diagnosis codes have been required on medical-scheme claims in South Africa since 1 July 2005.