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 

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


Category B: 


1.Claim Form Checks:

  • Reflecting principal insured’s details
  • Verify banking details (Account details on claimant correspond with claim form)


2. Hospital / provider account checks:

  • Incident date corresponds with date registered
  • Dependant
  • ICD-10 Code captured correctly
  • Any applicable discounts
  • Duplicate check – 4Web portal


5. Document checks:

  • All required documents are uploaded and named as per cheat sheet


4. Assessment Checks: 


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


5. Claim description field checks:

  • Admission + Discharge date
  • Password for password protected documents


Category C: 


1. Claim Form Checks:

  • Reflecting principal insured’s details
  • Date of Inception
  • Product option
  • Verify banking details (Account details on claimant correspond with claim form)


2. Hospital / provider account checks:

  • Incident date corresponds with date registered
  • Dependant
  • ICD-10 Code captured correctly
  • Any applicable discounts
  • Duplicate check – 4Web portal


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:


  • All required documents are uploaded and named as per cheat sheet


6. Claim description field checks:

  • Admission + Discharge date
  • Provider/s assessed
  • Password for password protected documents


Defined duplicate checks: 


  • Amounts 
  • Provider 
  • Patient 
  • Treatment date


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 FormClaim Form
Provider account for the doctorDr (provider's name) eg. Dr Greef
Provider account for the hospitalHospital account
Authorisation LetterAuth Letter
Letter or motivation email for stale claimMotivation
If a discount was providedDiscounts account (Provider Surname)

PMB Claims – Spesnet:


 

Types of claims: Notes: 
PregnancyAll birth claims PMB or not: Don’t send to Spesnet for clinical review until process has been finalized.
Momentum Co-paymentsAuth 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 hospitalNo Spesnet clinical feedback required
Stated benefitsNo Spesnet clinical feedback required
Out of hospital specialist consultation feesNo Spesnet clinical feedback required
Emergency Room - S codes or T codes with no admissionNo Spesnet clinical feedback required
Primary Care ConsultationsNo Spesnet clinical feedback required
All claims reflecting as a PMB on the assessment grid, other than specified aboveRefer claim to Spesnet for clinical feedback

Was this article helpful?

That’s Great!

Thank you for your feedback

Sorry! We couldn't be helpful

Thank you for your feedback

Let us know how can we improve this article!

Select at least one of the reasons
CAPTCHA verification is required.

Feedback sent

We appreciate your effort and will try to fix the article