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:
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
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.
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.
WHEN TO EXPECT PAYMENT
The law requires that we pay claims within 30-days; however, we pay claims twice a month. Exceptions apply from time to time; e.g. if we obtain better prices.
We always try and expedite refunds to members who have settled claims in cash. If you have paid cash, or you are charged above the Alliance-MidMed Rate, we will refund you directly.
HOW WILL YOU KNOW WHAT WAS PAID?
We send a statement to you at the end of each month
Register on the Alliance-MidMed website and view your statement electronically
Download and register on the Alliance-MidMed Mobile App and track your claims in real-time
HOW WE PAY GP’S, SPECIALISTS AND OTHER HEALTH PROFESSIONALS
We pay GP’s the actual cost of the consultation, up to a maximum amount that is adjusted from time to time.
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.
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.
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.
Annexure C of the Rules of the Scheme contains a list of exclusions. The exclusions will not apply to Prescribed Minimum Benefits or where Diagnosis, treatment, and care (specifical medicines) have been approved in terms of a Scheme health management programme. Limitations may apply in such instances, as is referenced in the Specialised Procedures/Treatment section in this document. Specific exclusions supersede general exclusions, and, amongst others, the following benefits are excluded:
Unregistered Health care professionals
Gum guards and gold dental work
Professional and speed contests/trials (main income derived from the contests)
PMB infertility treatment (State facilities)
Alcohol and other drug abuse, except for PMB
Appointments which a beneficiary fails to keep
Institutions like nursing homes not registered in terms of the law (except State facilities)
Medication not registered by the Medicine Control Council
Recuperation holidays (including headache and stress relief clinics)
Unproven treatment efficacy/safety
Scuba diving to depths below 40 meters/cave diving
Attempted suicide exceeding PMB limits
Costs exceeding annual Scheme Rule limits
Vasectomy/tubal ligation reversals
Circumcision, unless clinically indicated, or done in the GP rooms, and contraceptive measures/devices
Injuries/conditions resulting from willful participation in a riot, civil commotion, war, invasion, terrorist activity or rebellion
Travelling (excluding emergency transport)
Cosmetic treatment not directly caused by or related to illness, accident or disease
Breast reduction and breast augmentation, gynaecomastia, otoplasty and blepharoplasty