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)
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.
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.
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.