4.3 Provider Practice Codes
The Practice Code Numbering System (PCNS) is managed by the Board of Health care Funders. It is a list of unique practice billing codes for providers of health care services in South Africa, Namibia and Lesotho. The practice number allocated to all registered health care providers is a legal requirement for the process of reimbursement […]
4.2 Principle Member
The principle member is the main member on the medical aid scheme. Either one person or someone who has registered one or more dependents. The principal member pays a larger contribution than the dependents do. Medical schemes refer to dependents as beneficiaries.
4.1 Introduction
Every person who wants to join a medical scheme and can afford to pay the contributions can become a member of an open medical scheme. The principle of open enrolment means that any open medical scheme must admit any person who applies to be a member of that medical scheme. The practical implication is that […]
3.4 Health service Brokers
A. Definition Broker services entails advising clients on their financial services needs and includes the following: Providing clients with a number of quotes from different financial services companies for comparison. Matching potential clients up with companies that can meet their client’s unique needs. The Medical Schemes Act defines a medical schemes broker as a person […]
3.3 Managed Health Care
Managed health care is the clinical and financial risk assessment and management of health care, with a view to facilitating appropriateness and cost-effectiveness of relevant health services within the constraints of what is affordable, through the use of rules-based and clinical management-based programmes. The Medical Schemes Act defined rules-based and clinical management-based programmes as a […]
3.2 Administration of Medical Schemes
The business of a medical scheme is complex and transaction-intensive and includes the following: Managing applications for membership and evaluating applications. Registration of membership and tracking growth, resignations and suspensions. Managing and collection, control and reconciliation of the contributions received from membership. Loading of the rules of the scheme and managing benefits to members according […]
3.1 Introduction
The main agreements between medical schemes and third parties are the following: Administrators of medical schemes Managed care organisations Health service brokers Medical service providers Technology clinical support services The sections following considers some of these arrangements.
2.6 Management of a Medical Scheme
A. Board of trustees Medical schemes are managed by a Board of Trustees. The Medical Schemes Act requires that 50% of board members need to be elected from scheme members. The Medical Schemes Act also provides for people disqualified to be elected, for example, a person who is a director or an employee of an […]
2.5 Approval of Medical Scheme Options
Every option within a medical scheme represents a unique product with a specific range of benefits for a particular segment of the market. Every option has a set of benefits and a customised contribution rate for that particular option. Section 33 of the Medical Schemes Act allows for a medical scheme to apply to the […]
2.4 Rules of Medical Schemes
A. Introduction Whereas medical schemes in South Africa are governed and managed in terms of the Medical Schemes Act, each scheme is also governed in terms of its rules, which are also called its constitution, and which form the basis of the contract that members conclude with their medical scheme. Section 29 of the Medical […]