Agreement:
DENIS has been appointed by SAMWUMED in the form of a capitated agreement to provide dental risk management services to SAMWUMED from 01/08/2024.
Services Model:
DENIS will become the primary point of contact for dental benefit and dental preauthorisation requests for members and service providers.
DENIS will answer queries relating to all 2024 and prior queries and if required, will reprocess 2023/2024 claims to make corrections. This means irrespective of service date, all services as defined below are the responsibility of DENIS from 01/08/2024. There is no wind-down period managed by Medscheme for dental risk management.
Claims submission and queries will be based on the type of claim as there are some shared services between DENIS and Medscheme. The table below is a quick guide on routing and calls, correspondence and claims:
| Service | Benefit Period | Managed by | Member Contact | Provider Contact |
|---|---|---|---|---|
Dental Benefit Queries
|
All | DENIS | 0860 104 932 customercare@denis.co.za | 0861 033 647 customercare@denis.co.za |
Dental Preauthorisation Requests
|
All | DENIS | 0860 104 932 customercare@denis.co.za | 0861 033 647 crowns@denis.co.za ortho@denis.co.za perio@denis.co.za hospitalenq@denis.co.za |
| Dental Practitioner and Dental Laboratory claim submission and adjudication | All | DENIS | claims@denis.co.za | Claims switching house Or claims@denis.co.za |
| Hospital facility and anaesthetist claim submission and adjudication | All | Medscheme | Existing Process, no change Hospital: claimsmanagement@medscheme.co.za Anaesthetist: specialist@medscheme.co.za | Existing Process, no change Claims switching house Or Hospital: claimsmanagement@medscheme.co.za Anaesthetist: specialist@medscheme.co.za |
| Dental Practitioner and Dental Laboratory claim queries | All | DENIS | 0860 104 932 customercare@denis.co.za | 0861 033 647 customercare@denis.co.za |
| Hospital facility and anaesthetist claim queries | All | SAMWUMED | 0860 104 117 Existing Process, no change | 086 111 2666 Medscheme Provider Contact Centre |
| Membership Updates | All | SAMWUMED | 0860 104 117 Existing Process, no change | n/a |
| Dental Network Maintenance | All | DENIS | n/a | Existing Process, no change thenetwork@denis.co.za |
FAQS
- Yes, the process to hospital/day clinic and anaesthetist claim submission, adjudication does not change. This will be managed by Medscheme on behalf of SAMWUMED.
- DENIS interfaces details of the authorisation to Medscheme to facilitate the processing of the hospital/day clinic and anaesthetist claims.
- If a member has no, or incorrect email address, the Remittance Advice will generate and be stored on the DENIS Correspondence log. No post will be sent at this time. Members to update email details through administrator by calling the SAMWUMED contact centre on 0860 104 117 to update their details.
- DENIS cannot alter any membership information such as addresses, bank details etc.
This is to be sent to DENIS.
Please email customercare@denis.co.za
This is to be sent to DENIS.
Please send to hospitalenq@denis.co.za
This is to be sent to DENIS.
If you can tell what treatment type it is for send to the treatment specific address:
Crown and Bridge crowns@denis.co.za
Orthodontics ortho@denis.co.za
Periodontics perio@denis.co.za
If you are not sure, please email: customercare@denis.co.za
- A final claims run will be done by SAMWUMED on 04/08/2024. This will roll-up all claims received to the 31/07/2024.
- The next claims run for dental claims will be managed by DENIS.
- The claims will be rejected by Medscheme (claims processor for SAMWUMED) with a reference (rejection reason) to refer to DENIS.
- The provider or the member will need to resend the claims to DENIS via the switching house or to claims@denis.co.za
- Yes, DENIS has received the information of all the current (open) orthodontic cases, and they are loaded as active. This means claims can be submitted and processed as there is a valid authorisation. The values and approved time frames are loaded as approved by SAMWUMED
- Yes, DENIS has received the information of all the current (open) orthodontic cases, and they are loaded as active. This means claims can be submitted and processed as there is a valid authorisation. The values and approved time frames are loaded as approved by SAMWUMED
- From 01/08/2024 DENIS will be responsible for loading and adjudication of all new Orthodontic Preauthorisation requests.
Yes, DENIS has received the history for these instances for 2023 and 2024.
Yes, DENIS has received the full dental claims history for years 2019 to end July 2024 after which DENIS is responsible for processing of the Dental Practitioner and Dental Laboratory claims going forward.
