We’ve made the claims process easy to understand. Follow the steps below to see how your claim is submitted, what happens next, and what you need to know to help ensure it is processed smoothly.
In most cases, your healthcare provider will submit the claim to the Scheme on your behalf.
Over 90% of providers submit claims electronically (EDI), either in real time or in batches.
Most electronic claims are processed within three days, and payments are made twice a month.
If your provider charges at the Alliance-Midmed Rate and you have not paid them, the Scheme will pay the provider directly.
There may be exceptions, such as optical services.
If your provider charges above the Scheme rate, you may need to pay the difference. They can contact us on 0860 002 101 to discuss payment options.
Before receiving care:
- Confirm what your healthcare provider will charge
- Ask about any possible co-payments
After treatment:
- Pay any required co-payments directly
- Check your statements carefully
- Report any unusual or incorrect claims
It is your responsibility to ensure that:
- Claims are submitted correctly
- All claims on your statement are valid
If your provider does not submit the claim, you will need to do it yourself.
Make sure your claim includes:
- Membership number
- Surname and initials of the principal member
- Name and date of birth of the dependant (as per your membership card)
- Date of treatment
- Doctor’s valid practice number
- Tariff code and ICD-10 code
- Full cost of the service (split billing is not allowed)
Most pharmacies submit claims electronically.
If you need to submit one yourself, include:
- Name of medication
- Quantity or dosage
- NAPPI code
- Referring practice number
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
If your claim is not paid within 30 days:
- Call us on 0860 00 2101
- Email us at service@alliancemidmed.co.za
What to know about dental claims
Some dental treatments involve work done by a dental technician. The technician charges the dentist, and this cost is included in your claim. To avoid delays, make sure the technician’s invoice is included and complete. Missing details, such as your name or membership information, may result in delays or rejection of the claim.
If you submit claims manually, keep a copy for your records in case the original is lost. If you have already paid. If you have paid the account yourself, please submit:
- The account
- Proof of payment
This is required for the Scheme to process your refund.
To protect our members:
- Payments are not made by cheque
- Bank detail changes are only processed after strict verification
Please ensure that your banking details on record are correct and up to date.
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 healthcare 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
- Obesity
- Gum guards and gold dental work
- Professional and speed contests/trials (main income derived from the contests)
- Infertility treatment unless PMB
- Alcohol and other drug abuse, except for PMB
- Non-disclosure
- Appointments which a beneficiary fails to keep
- Unnecessary/inappropriate expenses
- Institutions like nursing homes not registered in terms of the law (except State facilities)
- Medication not registered by the Medicine Control Council
- Frail care
- Autopsies
- 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
- Shampoos and conditioners
- Telephone consultations
We’re here to help!
Our Member Support team is available Monday to Friday, 08:00 to 16:00.
If you contact us after hours, we’ll respond as soon as possible.
24-Hour Medical Emergency
0860 255426 (0860 ALLIANCE)
- Always present your membership card when receiving medical care
- Medical professionals are required to assist
in emergencies - Alliance-Midmed is a medical scheme,
not insurance
Scheme Call Centre
CALL: 0860 002 101
Hours: 07:00 to 16:30, Monday to Friday
After-hours membership confirmation is available on the same number.
For general queries after hours, please use the Member App or website.