Medical aid questions? Start here.

Yes. We can help you understand the rejection reason, check whether information may be missing, and assist with the appropriate next step such as a query, correction, resubmission or appeal process where applicable.

There are many possible reasons: incorrect member or provider information, an ICD-10 or tariff issue, a benefit rule, a missing authorisation, a late claim, a network requirement, insufficient available benefits or a scheme-specific rule.

Tip: Ask for the rejection reason or code in writing. It gives us something concrete to work from.

It generally means the benefit or limit the scheme uses for that service has been reached. It does not always mean there are no other possible benefits available. The wording, plan and clinical circumstances matter, so it can be worth checking what benefit was used and whether another funding route applies.

Possible reasons include an expired authorisation, formulary changes, a medicine or strength change, a DSP/network rule, a new prescription requirement or the medicine being claimed from the wrong benefit. ClaimSmart can help you work through the reason and identify what information may be needed.

We can assist with the administrative side of chronic and PMB processes, help identify required documents or information, and follow up where appropriate. Approval and clinical decisions remain with the medical scheme.

No. An authorisation confirms approval for a particular service or admission subject to the scheme’s rules. Co-payments, deductibles, network rules, provider charges above scheme rate and items outside the authorisation may still affect what is paid.

Yes. We can help you interpret benefit information, understand what questions to ask your scheme and identify the next practical step. We do not select a medical aid plan for you or guarantee future benefit availability.

Yes. We can help you understand a hospital or specialist shortfall, gather the usual supporting documents and work through the GAP claim process. Payment depends on your GAP policy terms and the insurer’s assessment.

Where appropriate and once the required consent or authority is in place, we can assist with calls, follow-ups and administrative queries on your behalf.

No. ClaimSmart provides administrative support and guidance. Medical scheme, insurer and provider decisions remain with those organisations. Our role is to help you understand what is happening, what information is needed and what the available next steps may be.

Phone, WhatsApp, email or use the enquiry form below. Give us a short summary of the problem. We can then tell you what documents or information we need before proceeding.

Ask what the authorisation covers, whether the hospital and specialists are in network, whether co-payments apply and whether any provider may charge above the scheme rate.

Keep invoices, statements, prescriptions, referrals, authorisation letters, rejection messages and proof of payment. A photo or PDF saved immediately is better than trying to find paperwork later.

A verbal “not covered” is difficult to investigate. Ask for the exact reason, rejection code or benefit rule used. This often tells you whether the issue is administrative, benefit-related or requires additional clinical information.

Incorrect or incomplete claim information can cause avoidable rejections. The healthcare provider should confirm the correct clinical coding. ClaimSmart can help identify when a coding or claim-information issue appears to be part of the problem.

Using a non-DSP or out-of-network provider can sometimes lead to co-payments or reduced funding. Check the rule before planned treatment whenever possible.

Schemes and insurers have submission deadlines. Do not leave a claim or query until the end of the claiming period. Early submission gives you more time to correct missing information if something goes wrong.

Do not assume the medicine is no longer covered. Check the chronic authorisation, formulary status, prescription validity, pharmacy/network requirements and the rejection reason.

Compare the provider account with the medical aid statement. Look at what was charged, what was submitted, what was paid and why any balance remains. This is also important when assessing a possible GAP Cover shortfall.