Medihelp aims to make claims processing hassle free for all healthcare professionals. To help us achieve this, here are a few tips on where, how, by when, and what information we need for quick processing.
Dental Risk Company (DRC)
Preferred Provider Negotiators (PPN)
Medihelp
The best and quickest way to submit claims is via electronic data interchange (EDI). If you don’t submit your claims in this manner, please speak to your software vendor to help you transfer your claims to our systems. The most important thing to remember is to check your statement to ensure that your claims were submitted.
It is ideal to submit a claim immediately after a service was rendered, but you have four months to submit new claims from the date of service. When you resubmit amended claims you have 60 days. This includes requests for information or payment queries from the date of the statement on which Medihelp reported the claim.
To ensure that your claims are valid according to the Medical Schemes Act and Medihelp's Rules, please ensure that the following details are on the account:
- The membership number of the main member
- The main member's name and surname
- The name, surname, and date of birth of the patient (Medihelp refers many claims back due to wrong patient information)
- Medihelp Medical Scheme - not "Private" (this has tax implications)
- The healthcare practitioner's name and practice code number
- The amount charged per item
- The amount you have charged
- The relevant code(s) such as ICD-10, NAPPI and item code(s) and that they are in the correct place when you submit it via EDI
- The date on which the service/procedure was rendered/performed
- The total of the claim balance
- Indicate any payments made by a member
When you scan in your claims, the account should not contain any modifications made by hand, as this will cause your claim to be invalid.
Claims procedure for pharmacies via Medihelp's PBM (Pharmaceutical Benefit Management) systemTo ensure that claims submissions via the PBM system are effective, please remember to:
- Ensure that the spelling of the patient's name as well as date of birth is correct and matches what is stated on the membership card
- Indicate the days' supply accurately;
- Remain within the over-the-counter (OTC) parameters, for example, for codeine- containing medicine and scheduled medicine items such as anti-inflammatory medicine or proton pump inhibitors;
- Ensure that the correct prescriber according to the latest prescription is captured on each prescription. This is especially important for the correct processing of claims for members of network options
- Update chronic medicine authorisations by emailing updates; to medicineapp@medihelp.co.za, indicating the membership number and ICD-10 codes on the prescription; and
- Capture the appropriate ICD-10 codes on each line where these codes are indicated on prescriptions. Also ensure that ICD-10 codes are valid, since invalid/incomplete ICD-10 codes could result in rejection of claims.
- If you are struggling with reversals you can send an email request to rx@medihelp.co.za for assistance. Please note that this email address is only used for support with PBM claims and not for enquiry purposes.
If you have any enquiries about your claims, email enquiries@medihelp.co.za.