Claims

Some healthcare providers submit their claims directly to the Fund, while others prefer that the member pay them directly after the consultation or treatment. If payment has been made by the member, the Fund will reimburse him or her once the claim has been processed.

Claims process

  • 1
    Check for the following information on your doctor's/healthcare provider's account.

    Required information

    Membership number Main member's surname and initials Patient's name Patient's beneficiary code Patient's ID number or date of birth The date on which the service was rendered Practice name Practice number Referring doctor's practice number (on specialist accounts) Nature of the treatment Treatment cost The pre-authorisation number, if applicable Tariff code(s) Relevant ICD-10 code(s) Nappi codes
  • 2
    warning Attach proof of payment if you have paid for a service. Proof of payment can be a receipt from the healthcare provider, an electronic fund transfer (EFT) or a bank deposit slip
  • 3
    Email

     

    [email protected]
    print Fax

     

    print011 381 2041/42
    OR
    Post
    Transmed Medical Fund
    PO Box 2269
    Bellville
    7535
  • 4
    The claim will be assessed and settled from your available benefits                                             
  • 5
    Claims are paid twice per month, i.e. in the middle and at the end of the month, depending on when your claim is received

Claims tracking

If we have your email address on record, you will receive a claims payment alert each time Transmed processes a claim for payment. These emails acknowledge the receipt of the claims, but are not a guarantee of payment.

You will receive a detailed claims statement once your claims have been processed. Please read your statement to see if your claims have been paid. If a transaction for services that you have not received is reflected on your claims statement, please report it to the Fund as soon as possible:

Refunds

When you have paid a healthcare service provider for a service, you may claim a refund from the Fund. Ensure that the Fund has your correct banking details as electronic refunds are made. To update your banking details the following information is required:

  • Account holder
  • Account number
  • Bank name
  • Branch code
  • Account type (cheque/current or savings)
  • A copy of your ID
  • A bank account statement, crossed cheque or letter from the bank with a bank stamp as confirmation (not older than three months)

You may submit your banking detail changes via any of the below communication channels:

Email:
[email protected]
Post:
Transmed Medical Fund, PO Box 2269, Bellville, 7535
Fax:
011 381 2041/42

Claims statement

You will receive a claims statement when a claim has been settled. Please read your claims statement to see if your claims have been settled. If a claim was rejected, your claims statement will show the rejection reason. Please resubmit the claim with the required outstanding information.

Transmed Claims Statements Explained
Frequent reasons for claims rejections (not paid)
  • Incorrect membership or dependant information reflected on claims
  • No pre-authorisation number obtained for service, such as for hospitalisation
  • Benefit limits have been exceeded
  • Claims have been submitted to the Fund after the four-month stale claim period
  • Due to Fund exclusions
  • Duplicate claims were received
  • Claims relate to treatment provided after a member has resigned from the Fund
  • ICD-10 codes on the claim are incorrect or not provided
  • Treatment received by a provider or facility that is not properly registered

Stale claims

It is a requirement of the Medical Schemes Act and the rules of the Fund that claims be submitted by no later than the last day of the fourth month after the service was rendered. Any claims submitted after this period will be considered stale and will not qualify for payment.

Should the Fund receive a claim from a service provider, such as a general practitioner or dentist, that is erroneous or unacceptable for payment, the Fund will notify you or your healthcare provider within 30 days of receipt of the claim and state the reasons for the rejection. Your healthcare provider will have the opportunity to resubmit a corrected claim within 60 days following the date on which it was rejected. Failure to submit the amended claim within 60 days will result in the account becoming stale and that it will no longer be eligible for processing.

warning Please note: It remains your responsibility to ensure that your claims are submitted within the required four-month period. If you have not made an upfront payment to the service provider, you remain liable for payment of his or her account until the claim has been successfully submitted to the Fund.