Hospital admission Procedure

Hospital pre-authorisation: 0860 10 11 76

Before you are admitted to hospital, you must phone for pre-authorisation except in the case of a life threatening medical emergency. This telephone call is important because it helps the administrator to confirm the procedure and appoint a designated case manager who will ensure that the rate charged by the hospital is correct. This will help you avoid having to settle an account or make co-payments when you are discharged from hospital.

 

Need-to-know admin details

How to submit a claim?

Following a consultation with, or treatment by, a provider, your account should reflect

if it has been submitted directly to Sizwe. If you are not sure, please enquire with your provider. If the account has not been submitted please follow the procedure below.  Be sure to submit your claims correctly in order to avoid any delays in payment. Mail or deliver your account as quickly as possible to your nearest Sizwe branch or your Broker.

1. Send only the original account you receive. Do not send statements or duplicate invoices.

2. Some doctors offer a discount if you settle the account immediately. If you have already paid the account, attach your receipt and mark the account “Refund Member”.

3. All accounts must show full details of your membership.

 

Please check that your account reflects the following:

– Provider’s name and practice number

– Principal (main) member’s name and initials

– Principal member’s medical aid number

– Treatment date

– Patient’s name (as listed on your membership card). If the patient is not the main member, please list their date of birth and ID number as well.

– Amount charged

– Tariff code (the doctor will fill in the ICD-10 code); and

– Diagnosis made by the doctor or specialist.

 

As proof that you have received the treatment that is being charged for on the account, please sign the account before submitting it to Sizwe. Claims are paid to providers every week and you will receive a monthly statement that shows all claims received and paid for since the previous statement. Pharmacies can submit claims in real time, on-line. This means that when receiving your medication at the pharmacy, you will know almost immediately whether Sizwe has accepted your claim.

 

Important:

– Only claims received within four months of date of treatment will be paid.

– Why wait for your refund cheque to be sent to you in the mail?

Sizwe can transfer any money owing to you electronically so that it appears directly in your cheque or savings account. To benefit from this electronic funds transfer (EFT) service, please fill in the special eft form, available at your nearest Sizwe branch or on the website.