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

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

Post: Send your claims to Anglo Medical Scheme P.O.Box 746, Rivonia, 2128

Fax: Fax your claims to 011 539 1008 (only use fax if you don’t have other communication channels as fax is often not clearly legible which might result in us not being able to process your claim)

Claims drop-off boxes: Drop off your claims in Discovery’s drop off boxes located for your convenience in most pharmacies, medical practices and at Virgin Active and Planet Fitness gyms nationwide

Remember: If your healthcare professional 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 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.

Ex Gratia requests  

Members may apply for benefits in addition to those provided in the Rules. An application will be considered by the Scheme which may assist members by awarding additional funding.

These awards are granted in cases of exceptional clinical circumstances or extreme financial hardship. Decisions do not set precedent or determine future policy as each case is dealt with on its own merits.

Submit the completed Ex Gratia Application Form using one of the following ways:

Email: ex-gratia@angloms.co.za
Fax: 011 539 1021
Post: Ex Gratia Department, P.O. Box 746, Rivonia 2128

Upon approval, submit your claims:

Email: ex-gratiaclaims@angloms.co.za
Fax: 011 539 1021
Post: Ex Gratia Department, P.O. Box 746, Rivonia 2128

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.

Chronic medicine advanced supply for travel 

Scheme will allow for the advanced supply of chronic medicine, for a period of three months within the current benefit year, to members on the Managed Care Plan who will be travelling. To qualify, you need to phone the call centre on 0860 222 633 and complete and submit the following:

  • An Advanced Supply Form
  • The prescription covering the travel period
  • A copy of the travel ticket or itinerary.

Overseas claims  

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 and complete the International Claim Form.
  • The account must give details of the healthcare service and state whether a general practitioner, specialist, pharmacy or hospital provided the service.
  • The Scheme will only reimburse into your South African bank account.

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.

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
  • 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 denture, 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
    • Wilful self-inflicted injuries.

General Rule Reminders

  • This Benefit Guide is a summary of the 2019 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 your dependant reaches the age of 23 and you wish to keep him or her on the Scheme as an adult dependant, you may apply for continuation of membership
  • 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.
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