Questions and answers from the year-end presentations
Q: If I pay a provider and submit the claim to the Scheme, how come the Scheme pays the provider again and I need to arrange a refund?
Answer: It is not ideal when this happens - it can result in frustration on your side and increased administrative work on our side. What are the possible reasons? You might have submitted the claim without your proof of payment, which obliges the Scheme to pay the provider. Your provider might submit the claim at the same time, which then again enables payment to the provider. In some instances, administration errors do occur, which is most unfortunate. On the Value Care Plan, you should only be using network providers who will claim from Prime Cure directly, so you don't have to pay at the rooms. Contracted providers will submit directly to the Scheme i.e. DRC dentists (on the Standard Care Plan) and Discovery GP Network providers (on the Managed Care Plan). You will not have to pay anything upfront unless your benefits have been exhausted. If you do submit a claim that you have paid at the time of the consultation, ensure that the provider has stamped 'Paid' on the account and that you have attached your proof of payment when submitting it to the Scheme.
Q: Why do we have networks in place, what are they and where can I find these network providers?
Answer: One way of keeping contributions low and reducing, or avoiding, co-payments, is to make use of networks, where rates, treatment protocols and services provided are agreed between the providers and the Scheme or administrator. If you are on the Value Care Plan, there are only a few exceptions where you would go out of network. For most of your health- care services, you need to consult a network provider. To find a Prime Cure network provider, you can search on www.primecure.co.za/provider-search or call 0861 665 665. Members of the Standard Care Plan and Managed Care Plan can find providers on a network by the third navigation point 'Find a provider'. There you can select the discipline (select from the suggested list) and area. In the list of results, under the provider's address, you will see whether they are part of a network or not. If you double click to open the provider information, you can read more about the network services offered at this provider. There are also network-provider lists you can download from the Scheme website, which you will find on the relevant benefit information page of your plan. If you don't manage to look up networks online, you can always call us on 0860 222 633 and we will assist you in finding a provider on the network. Please always check with your provider, before booking your appointment, that they are still on the relevant network. Sometimes new healthcare providers join these networks, sometimes providers leave these networks during the year. These are the main networks you should be aware of.
| Network | Standard Care Plan | Co-payment if you choose a provider outside the network | Managed Care Plan | Co-payment if you choose a provider outside the network |
| Day clinics for endoscopies, cataract surgery | Network of day clinics or accredited facility | R3 425 unless PMB or emergency | Network of day clinics or accredited facility | R3 425 unless PMB or emergency |
| Dentistry | Dental Risk Company network (DRC) | Difference between 80% of the Scheme Reimbursement Rate (DRC rate) and the claimed amount | n/a | n/a |
| General Practitioner | n/a | n/a | Voluntary Discovery GP Network | |
| Hospital network | Standard Care Plan hospital network | R3 425 unless PMB or emergency | n/a | n/a |
Published: November 2022.