Did you know that if a medical aid fund, or an administrator acting on behalf of a medical aid fund with regards to the administration and payment of ambulance claims, has not paid your claim promptly and in full, that you are entitled to lodge a complaint with the Council for Medical Schemes?
The Council for Medical Schemes (CMS), is described as a “statutory body established by the Medical Schemes Act (131 of 1998) to provide regulatory supervision of private healthcare financing through medical schemes.”
The CMS is mandated to ensure that medical schemes make payments to patients or providers in accordance with the regulations contained within the Medical Schemes Act (MSA).
A patient or provider is entitled to lodge a complaint with the CMS if they find that a scheme is not meeting their payment requirements in terms of the MSA. If the CMS agrees on the validity of the initial claim as well as the complaint, they will instruct the scheme to make the correct payment timeously for the claim.
In terms of the MSA, a scheme shall make correct payment of the account within 30 days after the day on which the account was received. This is provided that the rules of the scheme, as well as the provisions of the MSA, have been met.
If a scheme does not make payment on a claim within 30 days after the day on which the account was submitted to the medical scheme, and the scheme has not notified the member or the provider that the claim is erroneous or unacceptable for payment, then the patient or the provider is entitled to lodge a complaint with the CMS against the scheme concerned.
It is not the responsibility of the provider to constantly follow up with the administrator of the scheme in question, or to keep resubmitting the claim if the administrator claims that it did not receive it.
If the claim is a valid one, has not been paid within 30 days, and you have still not received any notification of a rejection of the claim within 30 days, then you should lodge a complaint with the CMS.
The correct complaints procedure, as well as the relevant form that needs to be completed in order to submit the complaint are described at the following link: