Approval Level 1 Checks

Modified on Mon, 29 Aug, 2022 at 12:13 PM

Approval levels are built into categories of approval per claimant:

Category A:

Portal to use: 4Web

Check if there are any claims registered for the same patient and same service date.
Check if client has reached their benefit limit for the specific benefit claiming for.

Category B:

1.Claim Form Checks:

2. Hospital / provider account checks:

5. Document checks:

4. Assessment Checks:

Totals and shortfalls captured must correspond with account and medical aid statement

5. Claim description field checks:

Category C:

1. Claim Form Checks:

2. Hospital / provider account checks:

3. Medical Scheme statement checks:

Incident date corresponds with incident on account
Amounts on the medical aid statement correspond with the charged amounts on the doctor’s account. (If no discounts have been applied)
Short payment reason code + Description

4. Assessment Checks:

Check assessment sheet under ‘Miscellaneous’.
Assessed under the correct benefit
Make sure that all tariff codes, charged amounts, scheme rate and paid amounts correspond with the medical aid statement. (Previously checked that provider account and medical aid statement correspond)
PMB = Spesnet document to be checked
Claim over R 12 000 = Spesnet document to be checked

5.Document checks:

6. Claim description field checks:

Defined duplicate checks:

Documents renaming cheat sheet:

Required documents attached onto the claim:

Claim form

Provider account

Hospital account

Authorisation letter

Motivation

If reflects as a PMB on the assessment grid = Spesnet feedback (Saved as confidential)

If a large loss claim = Large loss feedback and signed AOL

If a discount was provided = Discount account (Provider Surname) + Notes on Memo

Documents to be renamed as:

Document:	Rename as:
Claim Form	Claim Form
Provider account for the doctor	Dr (provider's name) eg. Dr Greef
Provider account for the hospital	Hospital account
Authorisation Letter	Auth Letter
Letter or motivation email for stale claim	Motivation
If a discount was provided	Discounts account (Provider Surname)

PMB Claims – Spesnet:

Types of claims:	Notes:
Pregnancy	All birth claims PMB or not: Don’t send to Spesnet for clinical review until process has been finalized.
Momentum Co-payments	Auth letter confirms that even if it’s a PMB the copayment will still apply if not a registered DSP on the network hence Gap will be liable. This will be discussed with Medcare and revert back to you regarding PMB case copayments, for now we pay as per the auth letter. Spesnet process for PMB must still be followed because if it is a DSP and comes back as PMB then the copay must be waived.
Cancer claims (Other than in hospital)	No Spesnet clinical feedback required
Co-payments / MRI / CT out of hospital	No Spesnet clinical feedback required
Stated benefits	No Spesnet clinical feedback required
Out of hospital specialist consultation fees	No Spesnet clinical feedback required
Emergency Room - S codes or T codes with no admission	No Spesnet clinical feedback required
Primary Care Consultations	No Spesnet clinical feedback required
All claims reflecting as a PMB on the assessment grid, other than specified above	Refer claim to Spesnet for clinical feedback