HEALTH PROFESSIONALS & HOW CLAIMING WORKS

In most instances, your Health Professional will submit claims to us directly. More than 90% of health professionals submit claims online through electronic data interchange (EDI) batch claims and real-time/online claims. Most EDI claims are processed and ready for payment within three days and payments are made twice a month.

If your Health Professional charges at the Alliance-MidMed Rate, and you have not paid them, we will settle the account directly with them. There are exceptions, like optical payments. If your Health Professional does not charge Alliance-MidMed Rates, please ask them to contact us at 0860 00 2101 to discuss payment options.

Please ensure that you know what your healthcare professional will charge before receiving the care/treatment. Settle co-payments directly and continue to check your statements and respond to suspicious transactions, claims values, repeat visits, and the like.

It remains your responsibility to ensure that claims are submitted correctly and that the claims which appear on your statements are legitimate. For a claim to qualify for payment, we require at least:

• Membership number
• The surname and initials of the principal member
• Name and date of birth of the dependant who received the treatment (this must be the same as on your membership card)
• Date of treatment
• Doctors’ practice number (must be a valid practice number)
• Tariff code and ICD 10 code
• Cost of service (including all costs, since split-billing is not allowed)

For medicine claims we require the following additional information (most pharmacies submit claims electronically, and therefore you will seldom need to refer to this):

• Name of medication
• Quantity/Dosage
• Nappi code
• The referring practice number

DENTAL TREATMENT CLAIMS

Dental treatment often requires additional work by a dental technician. The technician charges the dentist, who then adds the claim amount to your claim. We do experience challenges when the technician claim is not attached, or when it is incomplete, e.g. your name and details are missing. For hand-delivered copies, please ensure that you keep copies of your claims in the event of the original being lost.

If you have already paid an account, please submit the account and proof of payment with the claim, which we require to refund you.

FRAUD ALERT

Given the increasing amount of fraud, we do not make payments by cheque, and we only change bank account details after a rigorous check. Please ensure that we have your proper bank account details on record.

HOW WE PAY GP’S, SPECIALISTS AND OTHER HEALTH PROFESSIONALS

GP’s
We pay GP’s the actual cost of the consultation, up to a maximum amount that is adjusted from time to time.

Specialist
We pay specialists according to a maximum rate that we set in terms of affordability to the Scheme.

Contact us on 0860 00 2101 for the rate that applies to your specific specialist.

Certain specialists do not charge upfront co-payments or charge our members a lower co-payment. Please contact us for more information.

Please ensure that you are aware of the rates that certain specialists charge BEFORE UNDERGOING TREATMENT, including anesthetists.

The Scheme pays the first consultation to a specialist in a year at 250% of the Alliance-MidMed Rate to assist members with access.

Facility fees
We will request you, from time to time, to use specific facilities where the quality and costs are aligned. Should you then elect to use another facility or service, a co-payment will apply.

Preferred providers
We negotiate the quality of care and costs with our Preferred Providers and will advise where there may be additional costs. Additional costs usually relate to non-essential or elective services.

Other health professionals
We pay according to the Alliance-MidMed Rate that is available at 0860 00 2101 (we do not publish the list), or we negotiate a rate for the specific care where we do not use the services often or thirdly, we enter into a payment arrangement with the entity where our members are using the services/facilities regularly.