Out-of-network or non-DSP provider used

Check whether a DSP was actually available and accessible to you at the time. If it was an emergency, if no DSP was within reasonable reach, or if the DSP could not provide the service, the scheme is generally required to fund the care as though a DSP had been used. Ask the scheme to confirm in writing which DSP it says you should have used.

• 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.