Value Care Plan members belong to a network plan and may only use Prime Cure facilities or Prime Cure network healthcare providers, or both. Prime Cure pays these healthcare providers to provide you with healthcare services. You do not have to pay any accounts unless you have not complied with the Rules or use a healthcare provider outside the network in an emergency. If you receive healthcare services outside the network for an emergency, submit your claim as described below:
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:
If any of the above information is not correct or missing, the claim cannot be processed and Prime Cure 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.
You can also scan and email your claim to claims@angloms.co.za
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.
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 the Value Care Plan only provides primary healthcare through a network of Prime Cure facilities and providers in South Africa, claims outside the boarders of South Africa cannot be considered.
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 your plan.
The following are some of the Scheme exclusions (for a full list please refer to the Rules). These you would need to pay:
The following medicines are specifically excluded unless part of a PMB treatment and authorised: