Navigating the sometimes complex requirements related to medical aid claims can appear quite daunting, and some people even become so bewildered that they simply give up – and pay up.
There are some simple guidelines that you can follow to overcome these hurdles:
BEFORE YOUR VISIT TO YOUR HEALTH CARE PROVIDER (HCP)
Check whether the HCP is an approved service provider by your specific medical aid. Some schemes provide a list of Designated Service Providers (DSP) and these are usually paid in full. If you elect to consult someone other than a DSP who probably need to pay the difference in the fee
Check whether the HCP that you choose to visit is ‘contracted in’ to medical schemes. If not, the fees may be far higher than the amount covered by your medical aid. You may request medical aid rates if the HCP is ‘contracted out’ and again you would be liable for the costs not covered by your medical aid.
Always ask if discounts are available. Some HCPs are willing to give you a discount for services and/or products if warranted.
THE VISIT TO YOUR HCP:
- It is a good idea to check the points above again when you arrive.
- Ensure that all your details are correct and up to date
- Find out what fees will be applicable and if you will be responsible for any extras ( – e.g. if you need new spectacles – what is covered – lenses only, or frames, or is there a set amount?)
- If you receive a prescription for a chronic medication, find out if this is listed on the list of prescribed minimum benefits (PMB) and if these are covered by your scheme. If so, your HCP will need to sign a form to be submitted to the medical aid provider.
- It is your responsibility to ensure that this form is submitted, although some HCPs do so on your behalf.
- Be aware that if the first line therapy listed on the PMB fails, your HCP may motivate for a second line choice without incurring a penalty to you.
AFTER THE VISIT TO YOUR HCP:
- Ensure that any medical aid claim forms have been submitted.
- Follow up that all payments are made in accordance with the steps you have taken.
- If there are discrepancies, immediately consult your medical aid with your findings.
If necessary, you may contact us at Retina SA to provide you with the necessary forms to follow up on discrepancies.
James Cape- Chairman, Karen Denton, Siphiwe Sibisi and Claudette Medefindt at Retina SA head office.