Medical aid claim rejected: common reasons and how to fix them

Why was my medical aid claim rejected?

Start with the remittance advice or rejection notice. The scheme has to tell you why. Under Regulation 6 of the Medical Schemes Act regulations, a scheme that considers a claim erroneous or unacceptable must say so, with reasons, within 30 days of receiving it.

The reason is usually given as a short code or phrase. It will fall into one of three groups: something wrong with the claim, something about the member’s benefits, or something about your registration with the scheme.

Common medical aid claim errors

The first two account for a large share of rejections in mental health practice. Our guide to the ICD-10 anxiety codes shows what a complete code looks like, and the ICD-10 codes and tariffs page explains how the two kinds of code work together.

Rejections that aren’t errors

Sometimes the claim is correct and the scheme still doesn’t pay. These are benefit rejections:

• Benefits exhausted. The member’s savings or day-to-day benefit is used up for the year.
• Not covered on this plan. The plan doesn’t cover your service or your category.
• Session limit reached. Some plans cap the number of sessions per year.
• Authorisation needed. The benefit required pre-authorisation or a treatment plan.
• Paid at scheme rate. The scheme paid its rate, which is lower than your fee. This is a short payment, not a rejection.

Resubmitting won’t change any of these. The balance is for the client to pay, which is why your consent form needs to say who is responsible when a scheme doesn’t pay.

How to fix and resubmit

1. 1Read the reason on the remittance advice.
2. 2Correct the invoice. Don’t create a new invoice with a new number for the same session.
3. 3Resubmit with a note that it is a corrected claim.
4. 4Record the date you resubmitted.
5. 5Follow up if you hear nothing.

These dates are easy to lose track of across dozens of claims. Wholistic turns a claim deadline red 14 days before it passes, as part of its reminders.

How to appeal a rejected medical aid claim

If you believe the scheme is wrong, and correcting the claim hasn’t resolved it, the route is:

1. 1Query the claim with the scheme’s provider call centre and get a reference number.
2. 2If that fails, lodge a written dispute with the scheme. Every scheme has an internal disputes process.
3. 3If the dispute is not resolved, a complaint can be lodged with the Council for Medical Schemes, the regulator.

In practice the member often gets further than the provider. A scheme’s contract is with its member, so a client who phones about their own claim carries weight. Give them the claim details and the rejection reason.

How to bill the client when medical aid rejects

When a claim can’t be paid by the scheme, the account passes to the client. Handle it in a way that keeps the relationship intact.

• Tell the client promptly, and tell them the reason the scheme gave.
• Send a statement that shows the original claim, the rejection and the amount now due.
• Refer to the consent form they signed, which should say they are responsible for amounts the scheme doesn’t pay.
• Offer a payment arrangement if the amount is large.
• Follow up at regular intervals. The free payment reminder templates below have wording for each stage.

Preventing the next one

• Confirm benefits before the first session, not after the fifth.
• Capture medical aid details from the membership card, at intake.
• Save the codes you use, so they aren’t retyped on each invoice.
• Submit claims weekly. A claim sent the same week leaves months to fix a problem.
• Keep count of rejections by scheme. If one scheme rejects far more than the others, there is a pattern to find.