10. Payment of Claims

10.1 What information should be contained in a claim in order for it to be processed?

• Surname and initials of the member, membership number, name and date of birth of the patient, as well as the doctor’s practice number and the nature of service, relevant code, including ICD-10 code, service date and cost of each service rendered or item supplied.
  
• Medicine claims: the name, quantity, dosage and net amount payable by the member in respect of the medicine dispensed, as well as the relevant national pharmaceutical product
  interface (NAPPI) code and ICD-10 code. Non electronic accounts payable by the member must also be accompanied by a copy of the
  original prescription made out by a person legally authorised to prescribe the medicine (if applicable), and proof of payment must be attached.
  
• Dental claims: the number of each tooth treated.
  
• Surgical claims: the name, practice code and registration number issued by the relevant registering authority of every medical
  practitioner or dentist who assisted in the performance of that operation.
• Orthodontic or advanced dentistry services: the first account must contain the treatment plan showing the expected duration
  and total cost of the treatment, as well as the initial and monthly amounts payable.
  
  

Please note: Although orthodontic treatment is generally funded from the specialised dentistry benefit, certain parts of the treatment plan are classified under your Option’s benefits for basic dentistry. Please consult Selfmed to ascertain whether you will be responsible for certain costs in respect of your and your family’s orthodontic treatment.

10.2 When must I submit a claim for payment?

A claim must be submitted within four months from the end of the month in which the service was rendered. If not submitted within this period, the account will NOT be paid.

10.3 How will I know when my claim has been settled?

After your claim has been processed, you will receive a claim statement reflecting the payments made.

Note: If you received discount on an account, you will only be entitled to the
lower benefit amount after discount was taken into consideration.

10.4 Are benefits allowed in respect of foreign claims?

No benefits are allowed in respect of foreign claims, with the exception of claims originating in Namibia. Namibian claims will be processed and refunded to members in South African Rands.