No referral from your nominated network GP

Obtain a referral letter and the nominated GP's practice number and ask for the claim to be re-submitted with it attached. Where a referral was in fact issued but not captured, this is an administrative rejection that should be reversed without needing a formal dispute.

• 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.