SAMWUMED Claims Made Easy: 5 Steps To Avoid Rejection

How to Claim from SAMWUMED Without Getting Your Claims Rejected: A Member’s Guide

Navigating medical aid claims can feel like a maze, especially when a claim is unexpectedly rejected. For members of the South African Municipal Workers’ Union National Medical Scheme (SAMWUMED), understanding the claims process is crucial. By following a few key steps, you can avoid the frustration of rejected claims and ensure you get the benefits you are entitled to.

This guide will walk you through the essential steps to successfully claim from SAMWUMED, from preparing your documents to understanding why a claim might be rejected.

Step 1: Get Your Documents in Order (The Golden Rule)

The single biggest reason for claim rejections is incorrect or missing information. Before you even think about submitting a claim, make sure the invoice or account from your healthcare provider has all the necessary details. Think of it as a checklist you must complete.

Your invoice must include:

• Your Details: Full name and surname of the main member.
• Patient Details: The full name and surname of the person who received the treatment. If it’s a dependent, make sure to include their correct dependent code from your membership card.
• Membership Number: Your correct and current SAMWUMED membership number.
• Scheme and Option: The name of the scheme (SAMWUMED) and your specific benefit option (e.g., Option A or Option B).
• Provider Details: The healthcare provider’s name, practice number, and the referring doctor’s practice number if a specialist visit.
• Service Details: The exact date the service was provided, an account or reference number, and the correct tariff, NAPPI, or procedure code for each service.
• Diagnosis: The relevant ICD-10 code(s) for the diagnosis. This is a must-have for all claims.
• Cost Breakdown: A clear list of the amount charged for each service.

For medication claims, the name of the medicine, quantity, dosage, and net amount must also be on the invoice. Always double-check this information before you leave the doctor’s rooms or the pharmacy.

Step 2: Submit Your Claims On Time

Timing is everything. SAMWUMED has a strict deadline for claim submissions. All claims must be received by the scheme no later than the last day of the fourth month following the date of service.

Example: If you visited the doctor on August 15, your claim must be submitted before December 31 of the same year. Claims submitted after this deadline will be considered “stale” and will not be paid.

To ensure timely submission, consider using the SAMWUMED Mobile App. It allows you to scan and upload claims instantly, which is the fastest and most secure method. You can also submit claims via the member portal on the SAMWUMED website or through other designated channels.

Step 3: Always Get Pre-Authorisation

Pre-authorisation is not optional; it’s a non-negotiable step for many medical services. Failing to get pre-authorisation can lead to your claim being rejected or to you having to pay a significant co-payment, such as the R1,000 co-payment for specific hospital admissions.

You need to get pre-authorisation for:

• Hospital Admissions: For any planned hospital stay, you must get pre-authorisation at least one business day beforehand. In an emergency, a family member must contact the scheme on the first working day after the admission.
• Specialised Radiology: This includes in- and out-of-hospital MRI and CT scans.
• Oncology (Cancer) Treatment: All cancer-related treatments require authorisation.
• Chronic Medication: Authorisation is needed for chronic medication to ensure it is covered under the correct benefit.
• Certain Procedures: Some minor procedures performed in a GP’s or a specialist’s rooms may also require pre-authorisation. It’s always best to check with your provider or the scheme beforehand.

When you call for pre-authorisation, be sure to get a reference number. This number is your proof and should be given to your healthcare provider.

Step 4: Understanding and Responding to a Claim Rejection

Even if you follow all the steps, a claim might still be rejected. Don’t panic. The first step is to understand the reason. This will be clearly stated on your member statement, which you can access via the mobile app or the member portal.

Common reasons for rejection include:

• Benefit Exhausted: You have used up the annual limit for that specific service.
• No Pre-Authorisation: A required pre-authorisation was not obtained.
• Incorrect Information: There was a mistake on the invoice, such as a wrong code or membership number.
• Stale Claim: The claim was submitted after the four-month deadline.
• Contribution Arrears: Your medical aid contributions are not up to date.

Once you know the reason, you can take action. If it’s a simple administrative error, contact your healthcare provider and ask them to resubmit a corrected claim. If the rejection is related to your benefits or a dispute, you can contact SAMWUMED directly.

Step 5: The Complaints and Appeals Process

SAMWUMED is committed to resolving member complaints. If you are not satisfied with the outcome of a rejected claim, you can follow their formal complaints process:

1. Contact SAMWUMED: You can lodge a complaint by visiting a Walk-in Centre, calling the Call Centre, or emailing complaints@samwumed.org. The scheme will acknowledge your complaint within 24 hours and aims to resolve it within 30 days.
2. Escalate to the Dispute Committee: If you are still not satisfied, you can ask for your complaint to be referred to the scheme’s Dispute Committee.
3. Appeal to the Council for Medical Schemes (CMS): If the Dispute Committee’s decision is still not acceptable, you have the right to appeal to the CMS. The CMS is the official regulatory body for medical schemes in South Africa and can help with unresolved disputes.

By taking a proactive approach and ensuring all your documents are correct and submitted on time, you can navigate the SAMWUMED claims process with confidence. It all comes down to being informed and organised, so you can focus on what really matters: your health.

If you have questions, you can send an email to: samwumedclaims@medscheme.co.za or call: 0860 104 117 between 08h30 – 16h00, Monday to Friday.