Wellness Benefits

Wellness Benefits

Why should I go for screening tests?

Getting screening tests is one of the most important things you can do for your health. Screenings are medical tests that check for diseases before there are any symptoms. Screenings can help doctors find diseases early, when the diseases may be easier to treat.

How can the Wellness Benefits help me?

These preventative benefits are available on all Plans and consists of two types of Wellness Benefits: a Pharmacy Wellness Benefit, plus certain tests that can be conducted by a GP or specialist.

This benefit is separate from the Day-to-Day Benefit and is not paid from these limits, but subject to the use of the correct diagnostic and tariff codes as well as the correct Designated Service Provider.

The aim of this benefit is to encourage members to take care of their health and wellbeing by going for a general health consultation once a year and to keep track of their results.

What is available under the Pharmacy Wellness Benefit?

The Pharmacy Wellness Benefit gives you access to Clicks, Dis-Chem and Pick n Pay pharmacy clinics, where a qualified nurse will assess your current state of health and give you advice as well as tools on how to improve your health. Please note that you will be covered for one visit per beneficiary per benefit year and that these benefits are only redeemable from your Wellness Benefits if obtained from one of the listed pharmacy clinics.

At the clinic they can offer the following tests, measurements and services:

  • Blood pressure – Limited to 1 test per beneficiary per benefit year.
  • Blood glucose – Limited to 1 test per beneficiary per benefit year.
  • Cholesterol – Limited to 1 test per beneficiary per benefit year.
  • HIV/ Aids Test – Limited to 1 test per beneficiary per benefit year.
  • Body Mass Index (BMI) – Limited to 1 test per beneficiary per benefit year.
  • Flu vaccine – Limited to 1 vaccination per beneficiary per benefit year. (The cost of a visit to a General Practitioner is subject to the Day-to-Day Benefit.)
  • Pneumococcal vaccine – Limited to 1 vaccination per beneficiary per lifetime. (The cost of a visit to a General Practitioner is subject to the available Day-to-Day Benefit.)
  • Contraceptives – R2 990 per beneficiary per benefit year. R1 880 sub-limit for oral contraceptives. (Products must be prescribed for contraception and not for the treatment of acne or skin conditions, unless otherwise specified as per managed care protocols.) The cost of a visit to a General Practitioner or gynaecologist will not be covered under this benefit.

IMPORTANT: Please ask the General Practitioner, Gynaecologist or Urologist (whichever is applicable) to submit the wellness consultation claim using the following primary ICD-10 code: Z00.0. If this code is not used, the benefit will be paid from your available Day-to-Day Benefits.

 

TIP: Discuss your contraceptive options with your healthcare provider when you have your papsmear.

In addition to having your blood pressure, cholesterol, blood sugar, height, weight and body mass index measured and monitored, you can also ask the clinic staff for advice on how to improve your health through basic exercise and healthy eating plans.

Please contact your nearest Clicks, Dis-Chem or Pick n Pay Pharmacy clinic to make an appointment. Members may request a list of pharmacy clinics by emailing network.accounts@omsmaf.co.za.

If you wish to visit a Clicks pharmacy clinic to make use of this benefit, always present your OMSMAF membership card, which enables the Fund to obtain your results efficiently and pay for your visit.

What is available under the non-pharmacy Wellness Benefit?

Other wellness benefits available outside a pharmacy are the following:

  • Pap smear – limited to 1 test per female beneficiary per benefit year, including consultation with Registered Nurse, General Practitioner or Gynaecologist. This will also be an opportunity to discuss contraceptive options and get a script, if relevant.
  • Mammogram – limited to 1 test per female beneficiary per benefit year, including consultation with a Gynaecologist or GP. (Please note for the above Pap smear and Mammogram, only one Gynaecologist or GP consultation per benefit year will be funded from the Wellness benefit.)
  • Prostate Specific Antigen – limited to 1 test per male beneficiary per benefit year, including consultation with General Practitioner or Urologist.
  • Colorectal screening – limited to 1 test per beneficiary per benefit year.
  • Health Risk assessment – limited to 1 test per beneficiary per benefit year. Only for services rendered by a registered healthcare practitioner (for example, a General Practitioner).
  • Audiology screening – Limited to one test per beneficiary up to the age of 6 weeks.
  • PAED-IQ’s Babyline – A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age, who are registered on the Fund, can phone in and get up-to-date child healthcare advice and reassurance.

Any medical expenses not covered under the Wellness Benefit will be paid from your available Day-to-Day Benefits.

Travel Benefits

Travel Benefits

What should I keep in mind if I plan to travel outside South Africa?

IMPORTANT: Medical care abroad can be very expensive (depending on the country you will be travelling to) and, given our exchange rate, it may be wise to take out additional medical cover. Your travel agent will be able to assist you with this.

You will be glad to know, however, that you can claim from the Fund for medical expenses incurred while travelling outside South Africa. However, you need to be aware of the following:

  • You will be responsible for settling the account upfront. You can then claim the cost back from the Fund when you return.
  • If your account is in a foreign language, it must be fully translated and detailed before you submit it to the Fund.
  • Complete the claim form for foreign claims, which you can request from the Contact Centre. The more detailed your claim, the quicker the Fund can process it. You need to clearly indicate the following details:
  • The name of the country in which you were treated
  • Treatment dates
  • Whether there was anaesthesia involved and if so, how long it was for
  • The medicine, materials, treatment, procedures and operations involved. These must all be clearly specified and charged individually.
  • The patient’s name
  • The currency in which the claim was paid

 

TIP: Make extra copies of your passport and important documents.

Submit your original claim to: foreignclaims@omsmaf.co.za.

Your claim will be subject to the Fund’s Rules as if the treatment was rendered in South Africa. In other words, the same exclusions, benefits, and limits will apply.

Your claims will be paid according to the equivalent tariff and will be refunded to you in Rands, at the exchange rate that applied on the treatment date.

If you or one of your accompanying dependants use chronic medicine, you must also remember to arrange for advance supplies. Do so at least seven working days before you leave.

What if we have a medical emergency outside the borders of South Africa?

Members outside the borders of South Africa (members in Namibia, Lesotho and Swaziland) may call ER24 by dialing +27 10 205 3052 for the following services:

  • Life-threatening emergency (primary)
  • For primary service, but not life-threatening
  • Any inter-hospital transfers
Claiming Made Easy

Claiming Made Easy

What must I do if I have a claim?

Simply sign all original accounts, invoices and prescriptions and submit them directly to the Old Mutual Staff Medical Aid Fund (Claims). Remember to keep a copy for your records. Please note that claims that are faxed or submitted as scanned documents will only be processed if legible and received within the four-month claiming period. The payment run is every Thursday and it includes all claims to members and providers that were processed the previous week up and until Friday 12h00.

Members on the Network (including SELECT) Plans do not need to submit accounts for any service received at a Universal Healthcare Network practice as the practice will submit its accounts directly to Universal Healthcare. However, you can submit a claim for any medical costs not submitted by the practice, to Universal Healthcare, so that the claim can be processed for tax purposes.

Before submitting your claim, check that the following information appears on the account:

  • The name of the Fund and Plan, e.g. Traditional or Savings Plan
  • Your membership number
  • Surname and initials of member
  • The patient’s first name(s) and date of birth as it appears on your membership card
  • ICD-10 code
  • The date of service
  • Valid provider practice number
  • Valid attending provider practice number
  • Tariff code(s)
  • Quantities

In the case of accounts from a service provider such as a doctor or pharmacy, the name and practice number, as well as the chargeable code, should appear on the account.

If any of the above information does not appear on the account, this will lead to a delay in the processing of your account.

  • Check that the account details are correct and that you have been charged the correct amount.
  • If you have already paid the account, write “Account Paid” clearly on the account and attach the receipt.
  • Sign the original account and keep a copy for your records.
  • Submit your claim to OMSMAF via internal mail, post or email (see below).

Old Mutual Staff Medical Aid Fund (Claims) undertakes to settle the account within 30 days of receipt, and any money owing to you will be paid directly into your bank account recorded by the Fund via Electronic Fund Transfer.

Where do I submit my claim?
Via email: claims@omsmaf.co.za

Via internal mail: Old Mutual Staff Medical Aid Fund (Claims) Mutualpark

Via the post office: Old Mutual Claims, P O Box 1411 Rivonia, 2128

All claims for services rendered outside the borders of RSA: foreignclaims@omsmaf.co.za

How much time do I have to submit my claim?

Members on all OMSMAF Plans must submit their claims as soon as possible after receiving the service. If your claim is received later than four months after the date of service, your claim will be stale and your account will not be paid by the Fund. For example, if you visit the dentist on 20 April, you must submit your claim for that service before 1 September. If the Fund changes any of the benefits offered, claims submitted after these changes will be paid according to the Rules that existed at the date of the service and not the Rules that exist at the date when the claims are submitted or received.

How do electronic claims work?

The majority of service providers submit claims electronically. They are then paid directly, which means that you do not have to submit the account.

If your service provider uses this facility, ask them for a copy of the claim for your records and check that the services and amounts charged are correct. You do not have to submit a copy to the Old Mutual Staff Medical Aid Fund (Claims), unless you notice on your member statement that the claim has not been processed three months after the date of service. Remember, it is your responsibility to ensure that your claims have been submitted within the regulated time, by either checking your member statements or visiting the website regularly.

How is member debt created and recovered?

Member debt may be created if a claim is reversed or reworked. If you have a member debt, you will be required to pay the outstanding amount directly to the Fund.

If you use you full upfront savings credit and you terminate your membership during the benefit year, a member debt will be created that will need to be paid back to the Fund within 30 days of the termination date. Recoveries will also be made via Payroll.

Pensioners
Your member portion will be reflected on your monthly statement. Pensioners must pay member portions directly to the Fund.

Whom should I contact if I have any queries?

If you have any queries regarding claims, you should call the Contact Centre at 0860 100 076.