Helpful Hints

Phone a consultant TODAY!


Sizwe Medical Fund under provincial curatorship

Quote of the day

Q & A

Important telephone numbers

Client Services Tel Number:
0861 796 6400

Evacuation and After Hours Emergency:

0861 112 162

Submitting Claims

1. How do I go about submitting a claim?

All claims and accounts must be posted or hand-delivered to the Scheme as soon as they are received. No faxed copies are accepted, and the original documents are required in all instances. This is done in an attempt to eliminate fraud.

If you have already paid the account up front, and are submitting it for reimbursement, the receipt must be attached to the account and clearly marked – settled (paid) by member.

Remember: All accounts must reflect the following information:

  • The name and surname of the principle member
  • The first name, initials and surname of the patient (if the patient is not the principal member)
  • The name of the Medical Scheme – Health Squared Medical Scheme
  • Your membership number
  • The relevant diagnostic and other item codes that relate to the relevant health service provided
  • The date on which each health service was provided
  • The nature and cost of each health service rendered
  • Any name, quantity and dosage of any medication supplied to the member or dependent
  • The net amount payable by the member in respect of said medication

NB. Don’t forget to sign your claim before submitting it.

2. How long does it take for a claim to be paid?

Cheque runs are done twice every month.

All claims are assessed on a daily basis to ensure that invoices and prescriptions have all the required details as indicated above, and it is important that in order to prevent duplications, you check your statement before you resubmit a claim.

3. Who should submit the claim, the member or the service provider?

It must be made clear that the onus remains with the member to ensure that a claim is submitted timeously.

If you are provided with an account, you will submit it directly to the Scheme, or where you have paid the account upfront, you will submit the account for reimbursement. Service providers can submit claims directly to the Scheme and will then be paid directly. However, the member should follow up with the Scheme to ensure that the claim has been received.

4. What about Service Providers who are “contracted out”?

If the service provider you use is “contracted out” (charges rates above the National Price Reference Listing), Resolution Health will pay it’s portion in terms of the claim to the service provider, and should the member have a savings account (MCA), the outstanding amount will be paid from the MCA to the Service Provider, provided there are funds available.

5. What is EDI?

EDI stands for Electronic Interchange of Data. If this method is used to submit claims, the settlement process will be quicker. In order to use EDI, the service provider will need to be connected.

6. What is a “stale” claim, and what action should I take when a claim is rejected for this reason?

A claim is considered “stale” when it is submitted to the Scheme more than 4 months after the date of service by the medical service provider. If you have a “stale” account you will either need to provide proof that the claim was submitted within the 4 month timeframe, or alternatively you can write to the Scheme explaining the reasons for the late submission. The Scheme will then consider the merits of the case and make a decision accordingly.

Benefits and Added Value

Health Squared Medical Scheme works in conjunction with ER24 to ensure that your medical needs are taken care of as and when you need them. When it comes to hospitalisation ER24 can assist in getting you to hospital speedily under certain conditions.

*please refer to your Cover Option for information with regards to your hospitalisation cover.

1. Do I have full cover in hospital?

This depends on the plan you belong to. The following will apply:

  • If you are on the Fundamental Plan, you have unlimited cover in Network Hospitals and Provincial Hospitals only for PMB related conditions.
  • If you are on the Progressive Plan, a maximum of R200 000 per annum for a single person and R400 000 per annum for a family in any hospital for any condition. If the hospital benefit is depleted (R200 000 or R400 000), the member will have unlimited cover in Network Hospitals and Provincial Hospitals only for PMB related conditions.
  • If you are on the Prestige Plan, cover in respect of provincial and private hospitals is unlimited for any conditions and Resolution Health will pay 100% of the NRPL.

2. What is ER24?

ER24 is a 24-hour emergency response line. When you dial 084 124, highly trained personnel will be dispatched via vehicles, ambulances and helicopters to the relevant situations, while highly trained staff provide medical advice and information as well as emotional support.

2.1. Why is it necessary to contact ER24 for authorisation?

If you are unsure of whether an ambulance is needed, ER24 will be able to determine from the situation what is needed, thereby ensuring that a proper ambulance infrastructure is maintained for those situations that require an ambulance.

2.2. Should I be unable to contact ER24 and it is done on my behalf, will the claim be paid?

Yes, if the reference number is indicated on the account, it will be paid.

2.3. In what circumstances would it be permissible for me to obtain authorisation after the use of ER24?

In the event of the member being transported from the scene of an accident as an emergency, but the incident must be reported within 72 hours.

2.4. If I do not use ER24, will the account still be paid?

Yes, provided that the incident was reported within 72 hours, and a reference number is indicated on the account.


1. When is pre-authorisation required?

You will need to get pre-authorisation in the event of hospitalisation as well as the use of specified auxiliary services. Pre-authorisation should preferably be obtained 2 to 3 days in advance in order to streamline processes.

2. Is pre-authorisation a guarantee of payment?

Not necessarily. Benefits and membership information are only as accurate as the information available to the Scheme. The pre-authorisation is only valid for the information provided and is subject to the availability of benefits.

Health Squared, it’s trustees, or employees cannot be held liable under any circumstances for any claims, loss or damage whatsoever, whether direct, indirect or consequential and whether arising out of delict, contract or any other cause whatsoever which may arise out of the provision of inaccurate information by the member to Health Squared.