SAMWUMED Claims Procedure

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SAMWUMED is committed to paying member claims timeously. To enable the Scheme to honour this commitment members must understand and follow the below process:

1. Claim Submission Deadline

  • Claims must be submitted within four months (120 days) of the service date.
  • Claims received after this period will not be paid.
  • Copies of accounts will be accepted for processing the claims payment.
  • Where the healthcare provider rates are above the SAMWUMED rates, the member will be responsible for paying the balance directly to the provider.

2. Information Required

Members must submit the following information:

Beneficiary Information

  • Membership number.
  • Scheme name and benefit plan (Option A or Option B).
  • Main member’s initials and surname.
  • The patient’s name and surname.
  • If the claim is not for the principal member, the dependent’s code as it appears on the back of the SAMWUMED membership card is required.
  • Date of birth of the patient.


Treatment Information

  • The date of the service.
  • Account/reference number.
  • Valid Tariff/NAPPI/Procedure Code (pricing of a medical service/product).
  • ICD-10 code(s).
  • Cost of each treatment, item or procedure.
  • If the claim is related to medication the name, quantity, dosage and net amount payable by the member should be provided.
  • Healthcare provider (e.g. pharmacy, doctor, hospital, etc.
  • Name and practice number.
  • Referring doctor’s practice number (e.g. for specialist claim).
  • In the case of a group practice, the group practice number and the name of the practitioner who provided the service.

3. Payment of Claims

The outcome of the claim processing is communicated to the member via the Member Statement which members can access through:

  • The Mobile App (if they have downloaded it on their phones).
  • The SAMWUMED Member Portal (located on the SAMWUMED website).

4. Member Refunds

If a member paid for the service and wants a refund from SAMWUMED they need to submit the following:

  • Proof of payment (receipt or bank deposit slip).
  • Payment receipt from the service provider.

 

SAMWUMED-2024-Benefits