Approval level 2 Checks

Modified on Tue, 30 Aug, 2022 at 1:47 PM

Approval levels are built into categories of approval per claimant loaded: 


 

Value: Level 1:Level 2:
R 1 - R 2499No checksNo checks
R 2 500 - R 11 999Light checksLight checks
R 12 000 + (Excluding VAP claims) Intense ChecksIntense Checks

Category A: 


No checks


Category B: 


1. Claim Form Checks


  • Reflecting principle insured's details
  • Date of Inception
  • Verify banking details (Account details on claimant correspond with claim form) 


2. Hospital / Provider account checks


  • Any applicable discounts
  • Duplicate checks


3. Document checks


  • All required documents are uploaded 


4. 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’.
  • 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)
  • Assessed under the correct benefit
  • 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) e.g. 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:
Pregnancy All 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