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Sizwe Medical Fund under provincial curatorship

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Hospital Admittance and Claims

Claim Procedure

Should your medical service provider not submit claims to us electronically, please submit a signed claim to:

Resolution Health Medical Scheme

PO Box 1075



or email:

 Please include the following essential details:

• Membership number

• Name of the Option

• Member’s surname and details

• Surname, initials and other details of the patient

• The practice number, group practice number and individual provider registration number of the service provider; and in case of a group practice, the practice number of the practitioner who provided the service

• Date when the service was rendered

• The nature and cost of services rendered, including the supply of medicine to the member or registered dependant, with the name, quantity and dosage of the medicine – include the net amount payable by the member for the prescribed medicine

• The relevant diagnostic (ICD-10) code, relating to the service. If the ICD-10 code does not appear on the account it should be obtained from the service provider prior to submission

• If the member has already paid the account, the original receipt must be submitted with the claim

Claims must reach us by no later than the last day of the fourth month, following the month in which the service was rendered.

Accounts for treatment of injuries or expenses recovered from third parties must be supported by a statement detailing the circumstances in which the injury was sustained or the accident occurred. Claims payments to service providers and members take place twice a month. The Scheme will supply the member with a detailed claims statement on a monthly basis. Should there be any irregularities on the account, the Scheme will state the reason for the error or why it is unacceptable. The member or service provider then has the opportunity to return the corrected claim within 60 days of such notice.


Note: Certain service providers charge fees above those which are covered as listed in the membership guide. The Scheme will only pay providers at the rate depicted in the Benefit Schedule, usually the Scheme Rate unless otherwise specified. The Benefit Schedule also identifies limits and sub-limits for certain services and products. To avoid members being held liable for any shortfall, it is essential they determine what providers charge upfront prior to any services being delivered. The Scheme may also exclude certain services from benefits, as set out in Exclusions.


• You are able to obtain authorisation 24 hours a day

• All hospital admissions are subject to pre-authorisation, Scheme rules and managed care policies, protocols and formularies

• Authorisation must be obtained at least 72-hours in advance from the Scheme for all non-emergency hospital admissions and procedures. In the case of true emergency admissions, authorisation must be obtained within 48-hours or on the first working day after admission

• Laparoscopic and similar endoscopic procedures are excluded from benefits, unless pre-authorised otherwise under Scheme protocols

• Co-payments

• Members need to pay the following amounts upfront to the hospital when they are admitted for the procedures below

• Co-payments do not apply if these procedures are performed out of hospital or when it is a PMB condition.

When two related co-payments are applicable, only the larger will apply


Pre-authorisation is the application process for admission and procedure authorisation. We require the following information:

  • Membership Number
  • Dependant Name
  • Diagnosis
  • Procedure Codes
  • Hospital Name / Practice      Number
  • Date of Admission
  • Contact Details
  • Doctors Name

Toll Free Numbers

Hospital authorisations – 0861 111 778
CareWorks – 0860 101 110