In the 2018 financial year SAMWUMED processed and paid R1.1 billion worth of health related member claims.

Members are encouraged to assist the Scheme to process their claims quickly by submitting their claims correctly, says, Ntombizonke Kopie, Operations Manager for SAMWUMED. In many instances, delays in paying claims is because of incorrectly submitted claims, she added.

 

According to Mrs. Kopie, important things to be noted by members and service providers are the following:

  • A claim must be received by SAMWUMED within four months of the service being rendered for it to be paid.
  • In cases where a member paid the account or bill upfront and claims from the Scheme, the claim must be sent with an original receipt. Also within four months of the service taking place
  • Claim for costs of treatment of injuries or any expenses to be recovered from third parties, must be supported by a statement explaining how the injury happened

She further added that a claim must have the following information:

  • Surname and initials of the member
  • Name of the medical scheme
  • Medical Scheme membership number
  • The practice code number of the treating practitioner
  • The diagnosis code numbers
  • Date of treatment
  • Cost of the treatment including supply of medicine
  • Where the medicine is provided by a pharmacy, a copy of the original prescription or a certified copy of such prescription must be submitted

After processing and paying the claim, SAMWUMED sends confirmation to the member. It comprises amongst others of:

  • Name and membership number of the member
  • Name of supplier of the service;
  • Date of when the service was rendered
  • Total amount charged for the services concerned
  • Total amount payed to the service provider