Membership not active on the date of service

Request a membership history from the scheme and compare it against your contribution payments and employer payroll deductions. Where the contribution was paid or deducted, the rejection is administrative and should be reversed once the record is corrected.

• 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.