Medical aid and claims terms, explained

A

• Above Threshold Benefit (ATB)

  Day-to-day cover that starts once your claims have exceeded the annual threshold on certain comprehensive options. Payments are usually made at a defined scheme rate and may be limited to specific categories of treatment.

• Annual limit

  The maximum a scheme will pay for a category of benefit in one benefit year. Once reached, further claims in that category are declined, though Prescribed Minimum Benefit treatment must still be funded.

• Authority to act

  A signed mandate authorising a third party to correspond with your scheme and act on your behalf in a claim dispute. Schemes will generally not discuss a member's claim with anyone who cannot produce one.

B

• Beneficiary

  Any person covered by a medical scheme membership, including the principal member and all registered dependants. Prescribed Minimum Benefit entitlements apply to every beneficiary, not only to the principal member.

• Benefit year

  The twelve-month cycle over which your annual limits, thresholds and savings are calculated — for most South African schemes this runs from January to December. Limits reset at the start of each benefit year, and chronic registrations often need to be reconfirmed.

C

• Case manager

  A clinical staff member at the scheme who oversees an authorisation or admission, approves length of stay and monitors treatment against protocols. Case manager notes are often decisive evidence in a dispute about an admission.

• Chronic Disease List (CDL)

  The list of chronic conditions that all medical schemes must cover as part of Prescribed Minimum Benefits. It includes conditions such as hypertension, asthma, diabetes, epilepsy and HIV. Cover generally requires the condition to be formally registered with your scheme.

• Chronic medication list (formulary)

  The list of medicines a scheme will fund for a given chronic condition. Medicines outside the formulary are declined or attract a co-payment, but a prescriber can submit a clinical motivation where the listed alternative is unsuitable for you.

• Chronic registration

  The application process through which a chronic condition is recorded with your scheme so that medicine and related care are funded from the chronic benefit rather than savings. Registrations can often be backdated to the date of diagnosis, allowing earlier rejected scripts to be reprocessed.

• Claims shortfall

  The balance left over when a scheme pays less than a provider charged. Shortfalls usually arise from tariff differences rather than a denial of cover, and are the main risk that gap cover is designed to address.

• Claims statement

  The statement your scheme issues showing each claim received, what was paid, what was rejected, and the reason code for any rejection. It is the primary document needed to review a rejected claim, alongside the itemised provider account.

• Clinical motivation

  A letter from the treating doctor explaining why a particular treatment, medicine or admission was clinically necessary for you. It is the single most effective supporting document in reversing a rejection based on protocol, formulary or medical necessity.

• Co-payment

  A fixed amount or percentage you must pay yourself towards a claim, over and above what the scheme pays. Co-payments are commonly applied for using a non-network hospital, for certain procedures, or for admissions where authorisation was obtained late.

• Council for Medical Schemes (CMS)

  The statutory regulator of medical schemes in South Africa, established under the Medical Schemes Act 131 of 1998. The CMS registers schemes, supervises their conduct, and adjudicates member complaints that a scheme has not resolved internally.

D

• Deductible

  An upfront amount you must settle before the scheme funds the rest of a defined event, most often a hospital admission. It functions like a co-payment but is usually a set rand value payable directly to the facility.

• Dependant

  A spouse, child or other person registered on a principal member's medical scheme membership. Treatment for someone who was never registered, or whose registration lapsed, is routinely rejected on membership grounds.

• Designated Service Provider (DSP)

  A hospital, doctor, pharmacy or other provider your scheme has contracted with as its first-choice provider for certain services. Using a DSP usually means the claim is paid in full; using another provider commonly triggers a co-payment or a rejection, unless it was an emergency or no DSP was accessible.

• Diagnosis and Treatment Pair (DTP)

  The pairing of a specific condition with the treatment a scheme must fund for it under the Prescribed Minimum Benefit regulations. Whether a claim qualifies is decided by matching the diagnosis to its listed treatment pair.

• Discharge summary

  The clinical summary a hospital produces at the end of an admission, setting out the diagnosis, treatment given and follow-up plan. It carries the independent clinical evidence needed to test whether a rejection reflects what actually happened.

E

• Emergency medical condition

  A sudden and unexpected onset of a health condition requiring immediate treatment to avoid death, serious harm or lasting impairment. Emergencies are Prescribed Minimum Benefits, so cover cannot be refused merely because authorisation was not obtained beforehand.

• Ex gratia payment

  A discretionary payment a scheme may make where there is no benefit entitlement but the circumstances are exceptional. Ex gratia applications are decided by a committee, are not an entitlement, and should not be confused with enforcing a Prescribed Minimum Benefit, which is a legal obligation.

• Exclusion

  A treatment or service listed in the scheme rules as not covered at all on your option. Exclusions cannot lawfully be applied to deny Prescribed Minimum Benefit treatment or emergency care.

F

• Formulary

  A defined list of medicines a scheme funds for a condition, usually favouring generics and cost-effective alternatives. A prescriber may motivate for a non-formulary medicine where the listed option is clinically unsuitable.

G

• Gap cover

  A separate short-term insurance product, not a medical scheme benefit, that covers the shortfall between what a provider charges in hospital and what your scheme pays. Gap cover is regulated as insurance and has its own limits, waiting periods and exclusions.

• Generic substitution

  Dispensing a generic equivalent in place of the originator medicine. Schemes commonly fund only the generic price, leaving the member to pay the difference if they insist on the branded product without a clinical motivation.

I

• ICD-10 code

  The international diagnosis coding standard used on every South African medical claim. The ICD-10 code tells the scheme what condition was treated, and it is what determines whether a claim is assessed as a Prescribed Minimum Benefit. An incorrect or missing ICD-10 code is one of the most common causes of a rejected claim.

• Internal dispute

  The scheme's own formal review of a decision, usually handled by a disputes committee, which must be exhausted before escalating to the Council for Medical Schemes. Disputes must be submitted in writing and within the time limits set out in the scheme rules.

L

• Late joiner penalty

  A permanent surcharge added to contributions where someone joins a medical scheme for the first time later in life without prior cover. The penalty is calculated on the number of uncovered years and applies to the member's own contribution portion.

M

• Managed care

  The set of clinical and administrative tools schemes use to control cost and quality — pre-authorisation, treatment protocols, formularies, care programmes and provider networks. Managed care rules are lawful, but they may not be used to deny access to Prescribed Minimum Benefits.

• Medical Savings Account (MSA)

  A portion of your monthly contribution set aside to pay day-to-day claims such as GP visits, dentistry and acute medicine. Once the savings are used up, day-to-day claims are declined until the next benefit year, unless they fall under a risk or chronic benefit.

• Medical scheme broker

  An accredited intermediary who advises on scheme and option selection and is paid a regulated commission by the scheme. A broker's role is advice on cover, which is distinct from an independent review of a claim that has already been rejected.

• Medical Schemes Act 131 of 1998

  The primary legislation governing medical schemes in South Africa. It establishes Prescribed Minimum Benefits, sets the rules on waiting periods and underwriting, and creates the complaint and appeal process through the Council for Medical Schemes.

N

• Network hospital

  A hospital included in your option's contracted network. On network-based options, planned admissions must take place at a network facility for full cover, and admissions elsewhere are short-paid or declined unless an emergency exception applies.

O

• Open medical scheme

  A medical scheme that any member of the public may join, subject to underwriting rules. Open schemes are contrasted with restricted schemes, which are limited to employees of a specific employer, industry or profession.

P

• PMB level of care

  The standard of treatment a scheme must fund for a Prescribed Minimum Benefit condition, based on what is available in the public sector for that condition. Disputes often turn on whether the care actually funded met that standard.

• Pre-authorisation

  Approval obtained from your scheme before a planned admission, scan or procedure, confirming that the treatment will be funded and issuing an authorisation number. In an emergency, schemes generally allow authorisation to be obtained shortly afterwards, commonly within one working day.

• Pre-existing condition

  A medical condition you had, or received advice or treatment for, before joining a scheme. Schemes may apply a condition-specific waiting period to pre-existing conditions when you join, within the limits set by the Medical Schemes Act.

• Prescribed Minimum Benefits (PMB)

  A set of defined conditions that every registered medical scheme in South Africa must cover, regardless of which option you are on. PMBs cover a list of emergency conditions, a list of diagnoses and treatment pairs, and 26 chronic conditions on the Chronic Disease List. Cover for PMBs cannot simply stop because an annual benefit limit has run out.

• Principal member

  The person in whose name the medical scheme membership is held and who is responsible for contributions. The principal member is the scheme's point of contact for claims, disputes and changes to dependants.

• Procedure (tariff) code

  The code describing what the provider actually did — a consultation, scan, operation or test. Schemes price claims off these codes, so a mismatch between the procedure code and the diagnosis code will usually trigger a rejection or a request for clarification.

R

• Rejection reason code

  The short code and message a scheme uses to explain why a claim was not paid — for example 'no authorisation', 'benefit exhausted' or 'non-DSP'. The code determines what evidence is needed to dispute the decision.

• Remittance advice

  The document a scheme sends a provider explaining how each claim line was settled, including any rejection reason codes. Members can request it when the claims statement does not explain a rejection in enough detail.

• Restricted medical scheme

  A scheme limited to a defined group — such as public servants, police members, bank employees or graduate professionals. Eligibility is checked closely, and unregistered dependants are a frequent cause of rejected claims.

• Retrospective review

  A re-assessment of an already-processed claim, usually after new clinical information or a corrected code is supplied. Many schemes run a specific retrospective PMB review process for claims that were unpaid or short-paid.

S

• Scheme rate / tariff

  The price a scheme is willing to pay for a given service, often expressed as a percentage of a published rate. When a provider charges more than the scheme rate, the difference is billed to you as a shortfall — which is different from the claim being rejected.

• Section 47 complaint

  A formal complaint lodged with the Council for Medical Schemes under section 47 of the Medical Schemes Act, once a scheme's internal dispute process has not resolved the matter. The CMS investigates and issues a ruling that the scheme must respond to.

• Section 48 appeal

  An appeal against a decision of the Registrar of Medical Schemes, brought under section 48 of the Medical Schemes Act. Strict time limits apply, so the deadline stated in the scheme's or Registrar's correspondence should be diarised immediately.

• Self-payment gap

  The stage on some comprehensive options where your savings have run out but you have not yet reached the threshold at which the scheme resumes paying day-to-day claims. Claims in this window are for your own account, though they usually still count towards the threshold.

• Stale claim

  A claim submitted after the scheme's submission deadline, commonly four months from the date of service. Where the delay was the provider's, the outstanding account is usually the provider's to write off rather than the member's to pay.

• Sub-limit

  A smaller cap that sits inside a broader benefit — for example a limit on optical, dentistry or MRI scans within an overall day-to-day benefit. Sub-limits are a very common reason for a partly paid claim.

U

• Underwriting

  The assessment a scheme carries out when you apply for membership, based on your health history and previous cover. Underwriting determines whether waiting periods or a late joiner penalty apply, but it cannot be used to refuse membership of an open scheme.

W

• Waiting period

  A period after joining a scheme during which some or all claims are not paid. A general waiting period applies to all claims, while a condition-specific waiting period applies only to a named pre-existing condition. Both are limited in length by the Medical Schemes Act.

Still stuck on a rejection?