How do I submit a claim to the Scheme?

If you settle the account, please insist on an accurate invoice that reflects your payment. You can send the invoice and your proof of payment to the Administrator by post or email to the address listed below, and you will be reimbursed directly according to your benefits.

Information needed for claims submission

Ensure your claim is valid, you have received the treatment or services you have been charged for and that the following details are correct and complete:

Full name of main member
Membership number
Name of patient (main member or registered dependant)
Name of provider and practice number
Treatment date
Details of the service (tariff code, CPT code and explanation)
The diagnosis code (ICD-10)
Proof of payment if you have settled your account.

If any of the above information is not correct or missing, the claim cannot be processed and the Administrator will reject the claim. You might not receive notification if membership could not be verified. Please update your information with your healthcare provider and the Scheme regularly.

Upload: Scan and upload your claims in the member log in area of the website or on the Anglo Medical Scheme App

Email: Scan and email your claim to claims@angloms.co.za

Post: Send your claims to Anglo Medical Scheme PO Box 746, Rivonia, 2128

Remember: If your healthcare provider has already submitted the claim, you do not have to send us another copy.

What happens after I submit my claim?

The Scheme's administrator will usually process the claim within five days of receiving the claim. The Scheme has a claims payment run every week. We will make payments directly to you or your healthcare provider electronically. We will send you the claims statement twice a month if you have claimed, if not once a month.

Please check the claims statement to ensure your claim has been correctly paid. If you are asked for additional information, such as the date of service or a diagnosis code, please follow up on these requests to ensure a valid claim is resubmitted and to avoid final demand for payment from your healthcare provider. The Scheme will only consider claims submitted within four months of the date of service.

You can also, at any time, log in as a member on this website to check the status of your claim. If there is incorrect or missing information on the claim, the Scheme will notify you or the service provider on the statement.

Check, after submission of a claim, whether it has been processed.

You have 60 days from the date on which the claim was returned, to provide the correct information to the Administrator for processing, where-after the claim will be rejected and the Scheme will not be responsible for payment. If rejected, please always check the rejection codes as you may be required to act to ensure payment of your claims.

If, according to the Scheme Rules, the Scheme does not pay a portion, or the entire claim, you will have to pay the healthcare provider.

Keep and submit all receipts for payments made to healthcare providers to claim these expenses back from your personal income tax at the end of the financial year.

Deadlines

You (or your healthcare provider) have a maximum of four months from the date of treatment to submit a claim for payment. Thereafter the claim will be 'stale' and the Scheme will not be responsible for payment.

After the four months you will have to settle any outstanding amount without reimbursement from the Scheme.

In hospital claims

Claims that a hospital submits to the Administrator are charged according to the Scheme Reimbursement Rate and paid directly to the healthcare provider. Co-payments and Scheme exclusions will reflect as a shortfall and you will be responsible to cover the additional amount.

If you have paid cash for healthcare services, please attach your proof of payment so we can reimburse you. Always check whether your healthcare provider has submitted your claim directly to the Scheme's administrator. If so, do not re-submit a copy of the account.

Third-party claims

Anglo Medical Scheme Rules state that claims for costs that are recoverable from a third party (for example, the Road Accident Fund, or any other insurance fund) are not payable by the Scheme. However, the Scheme is aware that the time taken for these claims to be finalised can vary from a couple of months to years after the accident or incident.

As a result, the Scheme will agree to settle these accounts at the Scheme Reimbursement Rate on condition that the member provide a letter of undertaking, which states that the member will pay back any amount in respect of medical expenses that is recoverable from another source. On receipt of this letter, the Scheme will process the claim according to your available benefits and the Scheme Rules.

International claims

Emergency and acute medical treatment received when travelling or residing overseas
Members on the Managed Care Plan who travel or reside overseas and are not covered by any additional medical insurance and require medical treatment, are entitled to be reimbursed by the Scheme for the cost of the healthcare services as if they had been received in South Africa. The Scheme will consider, in accordance with the Rules and necessary authorisations, making a payment towards your overseas healthcare costs. We pay for costs according to the Scheme Reimbursement Rate (SRR) and Scheme Rules as well as the plan the member is registered on. However, you must remember the following when claiming a foreign account:

The Scheme will not pay a foreign healthcare provider, you must pay for the services at the time of the treatment.
If you are entitled to benefits from another insurer you must claim from that insurer first. Any shortfall or uncovered cost will be considered.
You must submit a fully specified account to the Scheme in English, complete the International Claim Form and send it with your proof of payment to the Scheme.
The account must give details of the healthcare service and state whether a general practitioner, specialist, pharmacy or hospital provided the service. Any payment made towards the cost of a claim will be made in South African Rands into your South African bank account. The amount paid will be at the average local equivalent cost and SRR had the service been obtained in South Africa in the Scheme's absolute discretion. Reimbursement will not be a direct foreign currency conversion into a rand amount. If the service is not available in South Africa, the amount paid will be for a similar or equivalent service if it exists. Remember that, except in the case of a medical emergency, the normal authorisation procedure needs to be followed before undergoing any routine or specialised treatment overseas

Please remember that you need to follow the normal authorisation procedure in the case of medical emergencies, before undergoing any routine and specialised treatment overseas inclusive of chronic conditions.
Repatriation and social transfers will not be covered.

We suggest you take out adequate medical travel insurance to cover any major medical emergency and in case you need repatriation from any country outside of South Africa, which is not covered by Netcare 911.

Ex Gratia requests

Members may apply based on the following criteria:

Demonstrated financial hardship in the case of a benefit depletion and the medical condition necessitates continuation of treatment; or
A genuine medical necessity where the benefit is expressly excluded from the Rules or is not provided for in the Rules.

Ex Gratia is not a guaranteed benefit and means "as a favour". Decisions do not set precedent.

Submit the completed Ex Gratia Application Form using one of the following ways:
Email: ex-gratia@angloms.co.za
Post: Ex Gratia Department, P.O. Box 746, Rivonia 2128

Upon approval, submit your claims:
Email: ex-gratiaclaims@angloms.co.za
Post: Ex Gratia Department, P.O. Box 746, Rivonia 2128

What you may not claim for

The following are some of the Scheme exclusions (for a full list please refer to the Rules). These you would need to pay:

Services rendered by any person who is not registered to provide healthcare services, as well as medicine that has been prescribed by someone who is not registered to prescribe
Experimental or unproven services, treatments, devices or pharmacological regimes
Patent and proprietary medicines and foods, including anabolic steroids, baby food and baby milk, mineral and nutritional supplements, tonics and vitamins except where clinically indicated in the Scheme's managed care protocols
Cosmetic operations, treatments and procedures, cosmetic and toiletry preparations, medicated or otherwise
Obesity treatment, including slimming preparations and appetite suppressants and bariatric surgery
Examinations for insurance, school camps, visas, employment or similar
Holidays for recuperative purposes, regardless of medical necessity
Interest or legal fees relating to overdue medical accounts
Stale claims, which are claims submitted more than four months after the date of treatment
Claims for appointments that a member fails to keep
Costs that exceed any annual maximum benefit and costs that exceed any specified limit to the benefits to which members are entitled in terms of the Rules

All costs related to:

Anaesthetic and hospital services for dental work, except in the case of trauma (PMB), patients under the age of seven years and the removal of impacted third molars
Bandages, dressings, syringes (other than for diabetics) and instruments
Lens preparations
DNA testing and investigations, including genetic testing for familial cancers and paternal testing
Gum guards, gold in dentures, crowns, inlays and bridges
Immunoglobulins except where clinically indicated against the Scheme's protocols
In vitro fertilisation, including GIFT and ZIFT procedures, and infertility treatments which are not PMBs
Organ donations to any person other than to a member or registered dependant
Willful self-inflicted injuries.

General Rule Reminders

This Benefit Guide is a summary of the 2024 AMS benefits as approved by the Council for Medical Schemes
The full set of Rules is available here
The Anglo Medical Scheme Rules are binding on all beneficiaries, officers of the Scheme and on the Scheme itself
The member, by joining the Scheme, consents on his or her own behalf and on behalf of any registered dependants, that the Scheme may disclose any medical information to the Administrator for reporting or managed care purposes
A registered dependant can be a member's spouse or partner, a biological or stepchild, legally adopted child, grandchild or immediate family relation (first-degree blood relation) who is dependent on the member for family care and support
To avoid underwriting, a member who gets married, must register his or her spouse as a dependant within 30 days of the marriage. Newborn child dependants must be registered within 30 days of birth to ensure benefits from the date of birth, if registered within 90 days, benefits will only be made available from the date of registration.
A child dependant, 23 years or younger on 01 January of a benefit year, may remain on your membership at the child dependant contribution rate until year-end. If your dependant is 24 years old on 01 January and you wish to keep him/her on the Scheme as an adult dependant, you may apply for continuation of membership against the Scheme's dependant eligibility criteria. If the criteria are met, adult contribution rates will apply
It is the member's or dependant's responsibility to notify the Scheme of any material changes, such as marital status, banking details, home address or any other contact details and death of a member or dependant.