Approval levels are built into categories of approval per claimant loaded:
| Value: | Level 1: | Level 2: |
| R 1 - R 2499 | No checks | No checks |
| R 2 500 - R 11 999 | Light checks | Light checks |
| R 12 000 + (Excluding VAP claims) | Intense Checks | Intense 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 Form | Claim Form |
| Provider account for the doctor | Dr (provider's name) e.g. 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 |
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