The short version
- Start with the scheme. Get the reason in writing, fix what can be fixed, and resubmit.
- If that fails, use the scheme's formal disputes process. Every scheme's rules must set one out.
- If you're still unhappy, lodge a complaint with the Council for Medical Schemes. It's free.
- A CMS ruling can be appealed, first to the CMS Appeal Committee and then to the Appeal Board.
- Most rejections come down to paperwork: a missing authorisation, a wrong code or a missing referral.
Why claims get rejected, and what to do
| Reason on your statement | What it usually means | What to do |
|---|---|---|
| No pre-authorisation | The treatment needed approval before it happened | Ask your doctor to request retrospective authorisation with a clinical motivation. For emergencies, schemes usually allow you to notify them within a set number of working days. |
| Benefit exhausted | Your day-to-day pool or a sub-limit has run out | Check whether the claim is a PMB. PMB claims must be paid from the scheme's risk benefit, not your savings or day-to-day pool. |
| Paid at scheme rate | The provider charged more than the scheme pays | The shortfall is yours unless it's a PMB treated at the scheme's designated provider. For in-hospital shortfalls, gap cover may pay. |
| Out of network / non-DSP | You used a provider outside your option's network | If you had no choice, for example in an emergency, ask for it to be treated as involuntary use. For a PMB, involuntary use of a non-network provider must be paid in full. |
| Waiting period | The claim falls inside a general or condition-specific waiting period | Check the dates against the waiting-period letter you got when you joined. |
| Incorrect or missing codes | The ICD-10 diagnosis code or procedure code is wrong or missing | Ask the provider to correct the codes and resubmit. This is the easiest fix. |
Step by step
- Read the claim statement. Note the claim number, date of service and reason code.
- Call the scheme and ask for the reason in plain terms. Write down the date, the consultant's name and the reference number.
- Fix what you can. Ask your doctor for corrected codes, a clinical motivation, a referral letter or a retrospective authorisation request.
- Send a written appeal to the scheme with the documents attached. Say exactly what you want: payment in full, payment as a PMB, or reprocessing.
- If the scheme still says no, ask for the matter to go to its disputes committee under the scheme rules.
- If that fails, lodge a complaint with the Council for Medical Schemes. Include the claim statement, your correspondence and the scheme's final response.
Is it a PMB? That changes everything
If the treatment is for a Prescribed Minimum Benefit condition, the scheme must pay for diagnosis, treatment and care at a defined level, on every option, whatever benefits you have left. Many successful complaints are PMB claims that were wrongly paid from savings or rejected as "benefit exhausted". Ask your doctor whether the diagnosis is a PMB and to use the correct ICD-10 code.
After a CMS ruling
Either you or the scheme can appeal a CMS ruling to its Appeal Committee, and after that to the independent Appeal Board. Each step has a time limit, so act as soon as you get the ruling.
Questions people ask
How long does a medical aid appeal take?
It depends on the scheme and on how complete your documents are. Keep a record of every call and get a reference number each time. If the scheme doesn't respond within a reasonable time, you can complain to the CMS.
Is there a medical aid ombudsman in South Africa?
Not as such. Complaints about medical schemes go to the Council for Medical Schemes, the regulator set up under the Medical Schemes Act. Complaints about insurance products such as gap cover go to the National Financial Ombud Scheme instead.
Does it cost anything to complain to the CMS?
No. Lodging a complaint with the Council for Medical Schemes is free.
Can I appeal a claim that was paid from my savings?
Yes, if it should have come from the risk benefit. PMB claims may not be paid from your medical savings account.
Related on Medical Aid Online
Sources
This guide is general information, not financial or medical advice. Medical Aid Online is not a medical scheme. Scheme rules and benefits change every year, so check the scheme's own rules and brochure before you decide.
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