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The claims you or your healthcare provider submit to the Scheme can be rejected for various reasons. For example, claims must be received by the Scheme for processing within four months from the date of receiving a service. A claim that is received after four months from the date of service is regarded as stale in accordance with the Medical Schemes Act and the Schemes rules. A claim that does not have all the information needed according to the Rules and the Act. If your claim is rejected due to outstanding information, you only have 60 days to resubmit, otherwise the account will not be paid.
Other common reasons why claims can be rejected include:
Check your claims statement regularly as the reason for rejection of claims will reflect on your statement, if any. For a useful and easy guide on how to interpret your claims statement, please refer to www.gems.gov.za > Members > Claims.
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