Submission of claims for medical treatment within 4 months after the treatment date

NHP reminds its members and healthcare providers that it is a requirement that all claims for healthcare treatment be submitted within 4 months after the treatment date. The Medical Aid Funds Act and the Rules of the Fund require that claims be submitted no later than the last day of the fourth month in which the service was rendered. Any claims submitted after this period will be stale and will not qualify for payment.

Should the Fund receive a claim from a service provider (i.e. doctor, dentist etc.) that is erroneous or unacceptable for payment, the Fund will notify the healthcare provider and/or member within 30 days of receipt of such claim and state the reasons for rejection. The Fund will then afford the healthcare provider and/or member the opportunity to resubmit a corrected claim within 60 days following the date on which it was rejected. Failure to submit the amended claim within 60 days will result in the account being stale and no longer eligible for payment. Should the 60 days fall within the 4 month period, the claim will not be deemed stale and will be settled by the Fund provided that all the documentation is in order to allow the Fund to process the claim for payment.

The same principle will apply where updates, motivations and any other additional information is required in accordance with the Fund Rules to process and pay claims.

It is important for members to understand that it remains his/her obligation to follow-up and ensure that all claims are submitted within the required 4 month period. Members remain liable to the healthcare provider for treatment done and the full balance of the invoice, irrespective of whether such claim was submitted and paid by the medical aid fund.

It is important to note that, once NHP has received, processed and paid for the original claim, no late billing or amended claim lines or amounts will be considered for payment. It is thus the member’s responsibility to ensure and check that accounts are submitted in full.

The claim run-off period for treatment up to 31 December 2016 will extend up to 30 April 2017. Any claim submitted after this date will be considered late and will thus not qualify for payment.

Stale claims

A Stale claim is a medical claim submitted to the Medical Aid Fund which is older than 4 months from the date of treatment and which has not been submitted in its entirety. A stale claim may also be a claim for medical treatment which was submitted and returned by the administrator for correction but which was not resubmitted for processing before the date the last day of the 4 month period following the month during which the medical service in question was rendered or during which the claim was returned for correction.

Where a claim submitted to the medical aid fund is found to be erroneous or unacceptable for payment, the medical aid fund shall inform the member concerned within 30 days of the receipt of the claim together with a printed statement stating the reasons why the claim is considered to be erroneous or unacceptable, and such member shall be afforded time to correct and resubmit such claim as stated above.

After 30 April of each year, no more stale claims in respect of the previous benefit year will be considered by your medical aid fund with the exception of cases stated above. In the event of a provider having submitted wrong codes on a statement these requests can be considered on application. However, the fund will not consider payment of stale claims if it is due to system changes and mistakes by creditors clerks if medical services were never billed in time on the side of the provider.

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