Discovery medical aid claims for psychologists: how to submit and what gets rejected

Before your first claim

Three things need to be in place, in this order:

1. 1An active BHF practice number, with the discipline matching your HPCSA category.
2. 2Registration of your practice with Discovery Health. Discovery asks for a completed practice registration form and supporting documents, sent to its practice registration team.
3. 3Confirmation of which codes Discovery recognises for your category on the member’s plan.

The third step is the one people skip. A practice number proves you exist. It doesn’t guarantee that a given plan pays for your service. Our guide to which medical aids to register with first covers registration with Discovery and the other main administrators.

How to submit a Discovery medical aid claim

There are two routes, and it helps to know which one you are using.

Discovery’s published guidance for members says claims can be emailed to claims@discovery.co.za with the membership number in the subject line, uploaded on the website, or scanned in the Discovery Health app. It also says claims must be submitted within four months, after which they are treated as expired.

Discovery states that claims are paid directly to the healthcare professional when they bill at the Discovery Health Rate. If you charge more than that rate, expect the scheme to pay the member, and collect from the client yourself.

What the claim must contain

Whichever route is used, the invoice is what the scheme assesses. It needs:

• Your name, practice number and HPCSA registration number
• The member’s name and membership number
• The patient’s name, date of birth and dependant code
• The date of each session
• The ICD-10 code for each line
• The tariff code for each line, and the amount charged
• Whether the account has been paid, and by whom

The free invoice template below has a field for each of these. In Wholistic the member details come from the intake form and the codes from your saved rates, as described on the ICD-10 codes and tariffs page.

What gets rejected

• The code isn’t valid for your category. Registered counsellors and psychologists bill different tariff codes. A psychologist’s code on a counsellor’s practice number is rejected.
• The ICD-10 code is incomplete. The code must be specific and complete. See our guide to the ICD-10 anxiety codes.
• The benefit is used up. Psychology is often paid from the medical savings account or a day-to-day benefit, which can run out during the year.
• The plan doesn’t cover it. Cover differs a great deal between plans.
• Member details don’t match. A wrong dependant code is a frequent cause.
• The claim is older than four months.

For conditions that qualify as Prescribed Minimum Benefits, additional cover may be available, usually on application and with a treatment plan. If a client has a qualifying diagnosis, it is worth asking the scheme what is required. Your session notes should support whatever diagnosis the application relies on.

The general fixes are in our guide to rejected medical aid claims.

Remittance advice reconciliation

After each payment run the scheme issues a remittance advice: a statement listing every claim it processed and what it did with each. Reconciling it means matching each line to your own invoices.

1. 1Match each line on the remittance advice to an invoice.
2. 2Mark each as paid in full, part-paid or rejected.
3. 3For a part payment, note the shortfall. That balance usually goes to the client.
4. 4For a rejection, read the reason and decide whether to fix and resubmit or bill the client.
5. 5Check the total against the amount that reached your bank account.

Done by hand, this is the most tedious job in a medical aid practice. It is also where money gets lost, because a short payment that isn’t noticed is never collected.

Other schemes work the same way

The principles carry over. If you are looking up how to submit a claim to Bonitas medical aid, or to any other scheme, the claim needs the same information and faces the same four-month limit. What differs is the administrator, the submission address and the plan rules.

Get each administrator’s provider guide and its payment run dates. Our guide to how long medical aid takes to pay explains how payment runs work.