Settling of Claims
The majority of doctors and other service providers submit claims directly to the Scheme using electronic data interchange (EDI). This process normally works extremely well and ensures quick, direct payment to service providers.
Some healthcare providers submit their claims directly to the Scheme, while others prefer that the patient pay them directly after the consultation or treatment. If payment has been made by the member, the Scheme will reimburse him or her once the claim has been processed.
You can scan or take a photo of your claim and email it to the Scheme. Please make sure the scan or photo is of a good, readable quality.
Members remain responsible for ensuring the payment of accounts.
The above-mentioned EDI process does not absolve the member from the ultimate responsibility for ensuring that the account is settled or from making any co-payment that is due.
Service providers who submit claims directly to the Scheme are obliged to send duplicate accounts to members in order for them to check whether the information on the account is correct.
You will receive a claims statement once your claim has been processed indicating how it was processed, what will be paid and when it will be paid. Check this statement and contact the Scheme if the information is incorrect.
Click here for a detailed explanation of your claims statement.
Check your claims statement to verify that your accounts have been paid. If an unpaid account is discovered after the maximum period of four months for the submission of claims has passed, it cannot be paid by the Scheme.
Imperialmed pays out-of-hospital claims at 85% of the Scheme rate and in-hospital claims at 100% of the Scheme rate. Many service providers charge more than the Scheme rate, which results in co-payments by members. Make sure you are aware of whether your service provider charges Scheme or private rates.
Imperialmed has two claims payment runs per month, i.e. in the middle and at the end of the month.
1Check for the following information on your service provider's account:
2gestureIf you submit the account, sign and date it and enclose proof of payment if you have already settled the account.
Email the account or a copy of the account to:ORPost
Post the account to:Imperialmed
PO Box 32759
4 Once the account has been processed, a claims statement will be generated and emailed or posted to you.
Frequent reasons for claims rejectionsIncorrect membership or dependant information No pre-authorisation number obtained for service, such as for hospitalisation Benefit limits exceeded Claims submitted to Scheme after four-month stale claim period Scheme exclusion Duplicate claims Treatment provided after resignation from Scheme ICD-10 codes incorrect or not provided Treatment received by service provider or facility that is not properly registered.