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Details needed to submit a claim

Our claims processing department have alerted us that they are currently receiving an increased number of claims which are missing information necessary for processing. To ensure that your claims can be managed as efficiently as possible, we would like to remind you about the details that need to be included when processing a claim. If any of the below information is incorrect or missing, we might not be able to process the claim or it might have to be rejected. If you didn't include information like your membership number or name, we might not even be able to notify you of this issue.

The following details need to show clearly on the account:

  • Membership number
  • Patient's name
  • Healthcare provider's name
  • Healthcare provider's practice number
  • Account number
  • Treatment date
  • Tariff or procedure or NAPPI codes
  • Amount claimed
  • Diagnostic code (ICD-10 code/s for each line billed)

Additional information needed when claiming for a refund from the Scheme:

  • A detailed claim invoice containing the information noted above
  • Proof of payment (Receipt/EFT Payment Slip)

For more information on how to submit a claim as well as what happens after you have submitted a claim, please search for "How to submit a claim" by using the magnifying glass on the top right.

Published: March 2021

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