Claim rejected

Charged above the scheme rate (tariff shortfall)

The provider charged more than the scheme's reimbursement rate, so the scheme paid its portion and billed the balance to you. The claim was not rejected — it was short-paid.

What to do next

For Prescribed Minimum Benefit treatment obtained through a designated provider, the scheme is generally obliged to fund the cost in full rather than leave a shortfall. Where PMB rules do not apply, ask the provider whether the rate was disclosed to you in advance and request a review of the balance.

Before you accept the decision

Ask the scheme, in writing, for the exact rule or code it relied on. A reason code on a statement is not a reasoned decision.
Check whether the treatment relates to a Prescribed Minimum Benefit. Option rules and annual limits cannot lawfully be used to refuse PMB care.
Compare the ICD-10 and procedure codes on the account against your clinical notes. Coding mismatches cause a large share of rejections.
Note the scheme’s internal dispute deadline, and the deadlines for escalating to the Council for Medical Schemes.

Other rejection reasons

No pre-authorisation obtained Out-of-network or non-DSP provider used Annual benefit limit or sub-limit reached Medical savings account exhausted Not a Prescribed Minimum Benefit condition Waiting period or condition-specific exclusion applies Claim submitted too late (stale claim)Incorrect or missing procedure / ICD-10 code Membership not active on the date of service Chronic medicine not registered on the programme Medicine not on the scheme's formulary Treatment excluded from your plan Treatment considered cosmetic or elective Duplicate claim No referral from your nominated network GP

Rejection Reversal

Have this rejection reviewed independently

Upload the rejection letter, the itemised account and the clinical notes. We test the scheme's stated reason against its own published rules and the Prescribed Minimum Benefit regulations, and produce a written review with a ready-to-send dispute pack where the rejection does not hold up.

Start a claim review

This page is provided for general information and does not constitute legal or medical advice. Medical scheme rules, benefit structures and regulations change over time — always confirm the position with your scheme’s current member material, your treating practitioner, or an attorney admitted in South Africa.

Landlodz (Pty) Ltd, trading as ClaimIQ SA
Registration No.: 2024/615543/07
ClaimIQ is a product of Landlodz (Pty) Ltd (Reg. No. 2024/615543/07).
Contact: info@claimiq.tech

ClaimIQ SA is an independent medical aid claim review and dispute service. We are not a medical scheme, a broker or a financial services provider.